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
$10,000
$100,000 $100,000
$50,000 $50,000
Included Included
$1,000
Baggage
Loss
(Not
available
for
CT
or
NY
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.
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o
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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)
o
Basic Plan Rate (see premium rates section) $ X months (whole months only) = $
o
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#
click to sign
signature
click to edit