Fill - Free fillable CISI-Basic-Plan-Coverage - 2015 Study Abroad Brochure Application2 _2

2015

World Class

Study Abroad Plan

An application of insurance for U.S. students studying abroad

administered by

Cultural Insurance Services International (CISI)

1 High Ridge Park Stamford,

CT 06905

Phone: 203.399.5556 Fax: 203-399-5596 Email: cisiwebadmin@culturalinsurance.com Web: www.mycisi.com

other offices: Bonn, Cape Town, London, Paris

This plan is underwritten by Arch Insurance Company, A Missouri Corporation (NAIC # 11150) Executive

offices are located at One Liberty Plaza, New York, NY 10006

Eligibility Requirements:

Citizens of the U.S. who are enrolled as full-time students at U.S.

institutions or on a recognized study abroad program and who are

temporarily engaged in international

educational or cultural activities

outside their home country are eligible for coverage.

The coverage effective date is noted in the Confirmation of Coverage to cover short

term limited duration trips. The effective and termination dates of coverage will appear on the Confirmation of Coverage and in no instance will coverage begin prior to the

effective date nor extend past the termination date or exceed 10 months.

SCHEDULE OF

BENEFITS

Basic Plan Coverages

Maximum limits

•

Medical Expense (per Accident or Sickness)

Deductible

Limit

•

Unlimited Lifetime Maximum

•

Accidental Death and Dismemberment

•

Medical Evacuation

•

Repatriation/Return of Mortal Remains

•

Team

Assist

Comprehensive

Plan Coverages

•

Medical Expense (per Accident or Sickness)

Deductible

Limit

•

Unlimited Lifetime Maximum

•

Accidental Death and Dismemberment

•

Medical Evacuation

•

Repatriation/Return of Mortal Remains

•

Team

Assist

Maximum limits

$100

$50,000 at

100%

Zero

$250,000 at 100%

•

Baggage Loss

(Not available for CT or NY Residents)

$10,000

$100,000 $100,000

$50,000 $50,000

Included Included

$1,000

•

Baggage

Loss

(Not

available

for

Residents)

$1,000

$50 deductible; $100 per

article (except for cameras $250)

$50 deductible; $100 per article (except for cameras $250)

•

Emergency

Medical Reunion

•

Trip Interruption

•

Security Evacuation Rider

$1,500

$500

$100,000

Covered Accident and Sickness Medical Expenses

Only such expenses, incurred as the result of a Disablement, which

are

specifically enumerated in the following list of charges, and which

are not

excluded in the Exclusions section, shall be considered as

Covered Expenses:

• Charges made by a Hospital for semi-private room and board, floor

nursing while confined in a ward or semi-private room of a Hospital

and other Hospital services inclusive of charges for professional service

and with the exception of personal services of a non-medical nature;

provided, however, that expenses do not exceed the Hospital’s average

charge for semiprivate room and board accommodation.

• Charges made for Intensive Care or Coronary Care charges and nursing

services.

• Charges made for diagnosis, Treatment and Surgery by a Physician.

• Charges made for an operating room.

• Charges made for Outpatient Treatment, same as any other Treatment

covered on an Inpatient basis. This includes ambulatory Surgical

centers, Physicians’ Outpatient visits/examinations, clinic care, and

Surgical opinion consultations.

• Charges made for the cost and administration of anesthetics.

• Charges for medication, x-ray services, laboratory tests and services,

the use of radium and radioactive isotopes, oxygen, blood, transfusions,

and medical Treatment.

• Charges for physiotherapy, if recommended by a Physician for the

Treatment of a specific Disablement and administered by a licensed

physiotherapist.

• Dressings, drugs, and medicines that can only be obtained upon a

written prescription of a Physician.

• Local transportation to or from the nearest Hospital or to and from the

nearest Hospital with facilities for required Treatment. Such

transportation shall be by licensed ground ambulance only, within the

metropolitan area in which the Insured Person is located at that time the

service is used. If the Insured Person is in a rural area, then qualified

licensed ground ambulance transportation to the nearest metropolitan

area shall be considered a Covered Expense.

Exclusions

For benefits listed in Section II, Schedule of Benefits, Accidental Death and

Dismemberment, this Insurance does not cover:

1. Suicide or attempt thereof by the Insured Person while sane or self

destruction or any attempt thereof by the Insured Person while insane;

2. Disease of any kind;

3. Bacterial infections except pyogenic infection which shall occur

through an accidental cut or wound;

4. Injury sustained while the Insured Person is riding as a pilot, student

pilot, operator or crew member, in or on, boarding or alighting from,

any type of aircraft;

5. Being under the influence of alcohol or having taken drugs or narcotics

unless prescribed by a legally qualified Physician or surgeon;

6. Injury occasioned or occurring while the Insured Person is committing

or attempting to commit a felony or to which a contributing cause was

the Insured Person being engaged in an illegal occupation.

7. Hernia of any kind;

8. Injury sustained while the Insured Person is riding as a passenger in

any aircraft (a) not having a current and valid Airworthy Certificate and

(b) not piloted by a person who holds a valid and current certificate of

competency for piloting such aircraft;

9. Any consequence, whether directly or indirectly, proximately or

remotely occasioned by, contributed to by, or traceable to, or arising in

connection with:

a) war, invasion, act of foreign enemy hostilities, warlike operations

(whether war be declared or not), or civil war.

b) mutiny, riot, strike, military or popular uprising insurrection, rebellion,

revolution, military or usurped power.

c) any act of any person acting on behalf of or in connection with any

organization with activities directed towards the overthrow by force of

the Government de jure or de facto or to the influencing of it by

terrorism or violence.

d) martial law or state of siege or any events or causes which determine

the proclamation or maintenance of marital law or state of siege

(hereinafter for the purposes of this Exclusion called the

“Occurrences”).

e) Any consequence happening or arising during the existence of abnormal

conditions (whether physical or otherwise), whether directly or

indirectly, proximately or remotely occasioned by, or contributed to by,

traceable to, or arising in connection with, any of the said Occurrences

shall be deemed to be consequences for which the Company shall not

be liable under this Policy except to the extent that the Insured Person

shall prove that such consequence happened independently of the

existence of such abnormal conditions.

10. Service in the military, naval or air service of any country;

11. Flying in any aircraft being used for or in connection with acrobatic or stunt

flying, racing or endurance tests;

12. Flying in any rocket-propelled aircraft;

13. Flying in any aircraft being used for or in connection with crop dusting or

seeding or spraying, fire fighting, exploration, pipe or power line

inspection, any form of hunting or herding, aerial photography, banner

towing or any experimental purpose;

14. Flying in any aircraft which is engaged in any flight which requires a

special permit or waiver from the authority having jurisdiction over civil

aviation, even though granted;

15. Sickness of any kind;

16. While riding or driving in any kind of competition;

17. Pregnancy, childbirth, miscarriage or abortion;

For benefits listed in Section II, Schedule of Benefits, Accident Medical,

Sickness Medical, Emergency Medical Reunion, this Insurance does not cover:

• Charges for treatment which is not Medically Necessary;

• Pre-Existing conditions, defined in this policy. This exclusion does not

apply to Emergency Evacuation/Repatriation;

• Injury or Illness claim which is not presented to the Company for payment

within 6 months of receiving treatment;

• Charges for treatment which exceed Reasonable and Customary charges;

• Charges incurred for Surgery or treatments which are,

Experimental/Investigational, or for research purposes;

• Services, supplies or treatment, including any period of Hospital

confinement, which were not recommended, approved and certified as

Medically Necessary and reasonable by a Physician;

• Injury sustained while participating in professional athletics;

• Routine physicals, immunizations or other examinations where there are no

objective indications or impairment in normal health, and laboratory

diagnostic or x-ray examinations, except in the course of a Disablement

established by a prior call or attendance of a Physician unless otherwise

covered under this Policy;

• Treatment of the Temporomandibular joint;

• Vocational, speech, recreational or music therapy;

• Services or supplies performed or provided by a Relative of the Insured

Person, or anyone who lives with the Insured Person;

• Travel arrangements that were neither coordinated by nor approved by the

Assistance Company in advance;

• Cosmetic or plastic Surgery, except as the result of a covered Accident; for

the purposes of this Policy, treatment of a deviated nasal septum shall be

considered a cosmetic condition;

• Elective Surgery which can be postponed until the Insured Person returns to

his/her Home County, where the objective of the trip is to seek medical

advice, treatment or Surgery;

• Treatment and the provision of false teeth or dentures, normal ear tests and

the provision of hearing aids;

• Eye refractions or eye examinations for the purpose of prescribing

corrective lenses for eye glasses or for the fitting thereof, unless caused by

Accidental bodily Injury incurred while insured hereunder;

• Congenital abnormalities and conditions arising out of or resulting there

from;

• Treatment in connection with alcoholism and drug addiction, or use of any

drug or narcotic agent;

• Expenses as a result or in connection with the commission of a felony

offense;

• Injury sustained while taking part in mountaineering where ropes or guides

are normally used; hang gliding, parachuting, bungee jumping, racing by

horse, motor vehicle or motorcycle and parasailing;

• Treatment paid for or furnished under any other individual or group policy

or other service or medical pre-payment plan arranged through the

employer to the extent so furnished or paid, or under any mandatory

government program or facility set up for Treatment without cost to any

individual;

• Expenses incurred while the Insured Person is in their Home Country,

unless otherwise covered under this Policy;

• Treatment for human organ tissue transplants or bone marrow

transplants and their related Treatment;

• Dental care, except as the result of Injury to natural teeth caused by

Accident;

• Routine Dental Treatment;

• Drug, Treatment or procedure that either promotes or prevents conception,

or prevents childbirth, including but not limited to: artificial insemination,

Treatment for infertility or impotency, sterilization or reversal thereof, or

abortion;

• Charges provided at no cost to the Insured Person;

• Injury sustained while under the influence of or Disablement due to

wholly or partly to the effects of intoxicating liquor or drugs other than

drugs taken in accordance with Treatment prescribed and directed by a

Physician for a condition which is covered hereunder [but not for the

Treatment of drug addiction;

• Injury sustained while participating in Amateur or Interscholastic

Athletics;

• Expenses which are non-medical in nature;

• Expenses as a result or in connection with intentionally self-inflicted

Injury or Illness;

• Treatment of venereal disease;

• Drug, Treatment or procedure that either promotes or prevents

conception, or prevents childbirth, including but not limited to:

artificial insemination, Treatment for infertility or impotency,

sterilization or reversal thereof;

• Expenses incurred during a Hospital Emergency visit which is not of an

Emergency nature;

• Covered Expenses incurred for which the Trip to the Host Country was

undertaken to seek medical Treatment for a condition;

• Covered Expenses incurred during a Trip after the Insured Person’s

Physician has limited or restricted travel;

• Sex change operations, or for Treatment of sexual dysfunction or

sexual inadequacy;

• Expenses which are non-medical in nature;

• Weight reduction programs or the surgical Treatment of obesity;

• Any consequence, whether directly or indirectly, proximately or

remotely occasioned by, contributed to by, or traceable to, or arising in

connection with:

a) war, invasion, act of foreign enemy hostilities, warlike operations

(whether war be declared or not), or civil war.

b) mutiny, riot, strike, military or popular uprising insurrection,

rebellion, revolution, military or usurped power.

c) any act of any person acting on behalf of or in connection with

any organization with activities directed towards the overthrow by

force of the Government de jure or de facto or to the influencing of it

by terrorism or violence.

d) martial law or state of siege or any events or causes which

determine the proclamation or maintenance of marital law or state of

siege (hereinafter for the purposes of this Exclusion called the

“Occurrences”).

e) Any consequence happening or arising during the existence of

abnormal conditions (whether physical or otherwise), whether directly

or indirectly, proximately or remotely occasioned by, or contributed to

by, traceable to, arising in connection with, any of the said Occurrences

shall be deemed to be consequences for which the Company shall not

be liable under this Policy except to the extent that the Insured Person

shall prove that such consequence happened independently of the

existence of such abnormal conditions.

The Company shall pay an indemnity determined from Section II Schedule of

Benefits, Accidental Death and Dismemberment, Table of Losses, if an Insured

Person sustains a Loss stated therein resulting from Injury, provided that:

1) such Loss occurs within 180 days after the date of Accident causing such

Loss; and

2) the indemnity payable for any such Loss shall be the Principal Sum stated in

Section II, Schedule of Benefits, Accidental Death and Dismemberment,

Principal Sum, as applicable to such Insured Person and this Insurance; and

if more than one Loss stated in said Table is sustained as the result of one

Accident, only one of the amounts so stated in said Table, the largest, shall be

payable.

EMERGENCY MEDICAL REUNION

When an Insured Person is traveling alone and is hospitalized for more than 6 days,

the Company will arrange and pay for round-trip economy-class transportation for a

Family Member, from the Insured Person’s Home Country to the location where the

Insured Person is hospitalized and return to the current Home Country. The benefits

reimbursable will include:

• The cost of a round trip economy air fare up to the maximum stated in

Section II Schedule of Benefits, Emergency Medical Reunion

All transportation in connection with an Emergency Medical Reunion must be

pre-approved and arranged by an Assistance Company representative appointed

by the Company.

TRIP INTERRUPTION

Trip Interruption coverage provides benefits up to the maximum stated in

Section II, Schedule of Benefits, Trip Interruption, Trip Interruption Limit, for

Loss(es) the Insured Person incurs for trips if interrupted after departure.

Coverage is provided for losses (after the Effective Date) the Insured Person

incurs due to the interruption of the Insured Person’s trip if caused by death of a

Family Member.

Coverage is provided for the cost of a one-way air or ground transportation ticket of

the same class as the unused travel ticket to return an Insured Person from the

International airport nearest to where the Insured Person was located at the time of

learning of such death or destruction to the International airport nearest to: (i) the

location of the funeral or place of burial in the case of the Unexpected death of a

Relative, or (ii) the Insured Person's principal residence in the case of substantial

destruction thereof; subject to the following conditions and limitations:

The Insured Person must be outside of his/her Home Country at the time of the

Unexpected death of the Relative; and

The Unexpected death of the Relative must have occurred during the Period of

Coverage; and

The Company will deduct from the Trip Interruption benefits payable hereunder the

value, if any, of the unused return ticket held by the Insured Person at the time of the

death, which value the Insured Person must attempt to receive credit for or apply

towards the costs of the return trip.

The Company will not provide any benefits, reimbursements or coverages for any of

the costs or expenses incurred by the Insured Person for a re-return trip, if any, to the

original location of the Insured Person at the time of learning of such death.

BAGGAGE AND PERSONAL EFFECTS

The Company will reimburse the Insured Person, up to the amount stated in Section

II, Schedule of Benefits, Baggage and Personal Effects, for theft or damage to

baggage and personal effects, checked with a Common Carrier] provided the

Insured Person has taken all reasonable measures to protect, save and/or recover

his/her property at all times. The baggage and personal effects must be owned by

and accompany the Insured Person at all times.

There will be a per article limit of $100; $250 for cameras.

The Company will pay the lesser of the following:

1. The actual cash value (cost less proper deduction for depreciation at

the time of loss, theft or damage;

2. The cost to repair or replace the article with material of a like kind

and quality; or

3. $100 per article.

For Baggage Loss, this Insurance does not cover:

1. Aircraft, automobiles, automobile equipment, motors,

motorcycles, bicycles (except bicycles when checked as

baggage with a common carrier,) boats or other

conveyances or their accessories;

2. Animals;

3. Artificial teeth or limbs, hearing aids;

4. Sunglasses, contact lenses or eyeglasses;

5. Documents of any kind, including but not limited to

documents, bills, currency, deeds, evidences of debt,

letters of credit, stamps, credit cards, money, notes,

securities, transportation or other tickets;

6. household furnishings.

Premium

Rates

World Class Study Abroad

Basic

Plan

World

Class

Study

Abroad

Comprehensive Plan

Age

Monthly

premium

Age

Monthly

premium

up to 25

$34

up to 25

$53

26–30 $55 26–30 $75

31–40 $84 31–40 $112

41–50 $107 41–50 $123

51–60 $201 51–60 $237

61+ $297 61+ $354

These

rates

are

valid

until

December

31,

2015

Full

months only, please.

Leaving soon…?

Enroll online at www.mycisi.com (click on view plans)

STUDY ABROAD PLAN ENROLLMENT FORM

Please print. Call 203.399.5556 or e-mail cisiwebadmin@culturalinsurance.com with any questions. Credit card

enrollments can be faxed to 203.399.5596.

PARTICIPANT CONTACT INFORMATION:

Name Female Male

U.S. Mailing Address

City State Zip

Telephone number Email

Date of birth

PROGRAM INFORMATION:

U.S. institution where enrolled as student (if applicable)

Institution sponsoring study abroad program (if applicable)

Name of international institution you will attend

Host country

Program start date

ENROLLMENT INFORMATION:

Program end date

I want my insurance to begin / / and continue for months (maximum 10 whole months only)

Basic Plan Rate (see premium rates section) $ X months (whole months only) = $

Comprehensive Plan Rate (see premium rates section) $ X

Months

(whole months only)

Total premiums = $

Beneficiary’s name Relationship

PAYMENT INFORMATION:

Check/money order enclosed

Visa

MasterCard American Express

Please provide the following additional information for credit card payments:

Card number

Expiration date /

Cardholder’s name (please print)

I have read and understand the terms and conditions of the policy and authorize payment for the above enrollment.

Signature Date

All insurance materials are sent via email. If you are paying by check, make checks payable (U.S. funds only) to CISI and mail with completed enrollment from to:

CISI, 1 High Ridge Park, Stamford, CT 06905. Paying by credit card? Feel free to mail as well or email to CISIwebadmin@culturalinsurance.com or fax to

203.399.5596. Please contact CISI if you have any questions about this form or policy.

For office use only

2015

Participant ID#

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signature

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