Diplomat LT

Accident & Sickness Plan that covers you inside or outside the United States (3 months up to 365 days*)

* Participant can re-apply for additional periods of coverage not to exceed 3 years total. Any subsequent new periods of coverage will not include a pre-existing condition limitation and will be issued at the guaranteed rate.

Maximum

Traveling to the United States

Plan A - $500,000, Plan B - $1,000,000

Traveling Outside the United States

Plan A - $500,000, Plan B - $1,000,000
Persons age 65 - 69 maximum benefit of $100,000;
Persons age 70 - 79 maximum benefit of $50,000;
Persons age 80+ maximum benefit of $20,000.

Deductible Choices

$0, $50, $100, $250, $500, $1,000, $2,500, $5,000 per person/plan period

Co-Insurance

Traveling to the United States

After you pay the selected deductible, the plan pays 80% up to $5,000 of eligible costs, then 100% to the Medical Maximum. There will be an additional $250 deductible for each emergency room visit as a result of an Illness. The ER deductible will be waived if hospital admittance is within 12 hours of the incident.

Traveling Outside the United States

After you pay your selected deductible, this plan will pay 100% of Covered Expenses outside the USA up to the selected plan maximum.

Pre-Existing Condition Exclusion

18 Months prior to the start date of coverage

Emergency Medical Evacuation and Repatriation

$250,000

Return of Mortal Remains

$50,000

Emergency Medical Reunion

$50,000

Return of Minor Child

$50,000

Interruption of Trip

$5,000

Loss of Baggage

$50 per article; up to a maximum of $250

Emergency Dental Treatment

Accident: Usual & Customary Expense
Palliative: $100

Accidental Death and Dismemberment

$25,000 (Enhanced Benefit Amounts available) with paralysis and coma, seat belt and airbag, felonious assault and home alteration and vehicle modification benefits.

In-Hospital Indemnity (US Citizens only)

$100 per day to a maximum of 10 days

Unexpected Recurrence of a Pre-existing Condition (US Citizens only)

up to $20,000; ($2,500 for age 65 and older)

Optional Plan Enhancements

• Athletic & Hazardous Activity Benefit
• Home Country Coverage
• War Risk Coverage: Available outside the USA, call us for a quote.

Political and Natural Disaster Evacuation

$50,000

This International Accident & Sickness insurance plan is designed to cover anyone traveling outside their home country. The flexibility of this plan makes it ideal for business and leisure travelers, expatriates, study abroad, work study programs, international exchange students, tourists, and church or missionary travelers.

Why do long-term international travelers need this coverage?

Problem for U.S. Travelers

Most group and individual health plans sold in the United States provide limited coverage while traveling overseas. PPO's do not extend their network's abroad, so any difference in billing expenses or claims that are not considered eligible expenses will become the responsibility of the insured. Medicare provides no coverage outside the U.S. (see U.S. Passport for details).

Problem for Non - U.S. Citizens

Nationalized or government sponsored health plans rarely provide adequate medical coverage for illnesses or injuries sustained while traveling outside your home country. Extreme sports, hazardous activities, emergency medical air evacuation and repatriation are usually not covered under nationalized health insurance schemes. Most travelers to the United States are innocently unaware of how expensive medical care and treatment can be in the U.S. Not to mention, that medical care in the U.S. is usually provided through HMO's or managed care facilities, which may not recognize a "foreign insurance company" or government sponsored health plan.

This brochure is meant to be a brief summary of the plan features only for the Diplomat LT Plan and does not cover all the terms, conditions and limitations of the Plan Document - the Plan Document will govern in all cases. Benefits and plan costs are subject to change.

Eligibility

The Diplomat LT provides Accident and Sickness Medical Coverage and AD&D benefits to those traveling outside their Home Country (For coverage inside the U.S., you must be a Non-U.S. Resident). Coverage is available for you, a second adult, unmarried dependent Children, or Children traveling alone. Travel assistance services are also available.

Period of Coverage

The minimum initial period of coverage that can be purchased is 3 months, the maximum is 365 days. Participant can re-apply for an additional term of 365 days of coverage. Any subsequent new periods of coverage will not include a pre-existing condition limitation and will be issued at the guaranteed rate. A participant is eligible to reapply for up to 2 separate terms from the date of the initial enrollment with this guarantee.

Effective Date

A Person will become a Plan Participant under the Plan Document, provided proper premium payment is made, on the latest of:

1. The date the Company receives a completed application or enrollment form; or
2. The moment Plan Participant exits their Home Country airspace; or
3. The Date the Company approves the Application; or
4. The Date requested by the Plan Participant.

Termination Date

Insurance for a Plan Participant will end on the earliest of:

1. The date Plan Participant is no longer in an Eligible Class; or
2. The date the Plan Participant's Trip is completed, unless otherwise covered under the Plan Document; or;
3. The expiration of 365 days from the Effective Date of Coverage; or
4. The date shown on the Schedule of Insurance issued by the Company.

The Diplomat LT plan was designed mainly to provide accident & sickness and evacuation coverage for foreign nationals traveling inside the USA or for US Nationals traveling outside the USA. This plan is also available for Non-US residents who travel outside of their home country.

Description of Coverage

All plan cost and benefits will be paid in U.S. dollars. We will pay Usual and Customary charges for Covered Expenses incurred during your travel. Benefits in excess of your chosen deductible and co-insurance, up to the selected Medical Maximum will be considered for payment. The initial Treatment of an Injury or Illness must occur within 30 days of the date of Injury or onset of Illness.

Covered Expenses

Only such Expenses that are specifically enumerated in the following list of charges that are incurred for medical care and supplies which are: (a) necessary and customary; (b) prescribed by a Physician for the therapeutic treatment of a disablement; (c) are not excluded under the plan; (d) are not more than the Usual and Customary charges (as determined by the Company); and (e) are incurred within 180 days from the date of the Disablement will be considered.

• Expenses made by a Hospital for room and board, floor nursing and other services, including Expenses for professional services, except personal services of a non-medical nature, provided, however, that Expenses do not exceed the Hospital's average charge for semi-private room and board accommodation.
• Charges made for Intensive Care or Coronary Care charges and nursing services;
• Expenses 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, Physician's Outpatient visits /examinations, clinic care, and surgical opinion consultations.
• Expenses made for administration of anesthetics.
• Expenses for medication, x-ray services, laboratory tests and services, the use of radium and radio-active isotopes, oxygen, blood transfusions, iron lungs, and medical Treatment.
• Hotel room charge, when the insured, otherwise necessarily confined in a Hospital, shall be under the care of a duly qualified Physician in a hotel room owing to the unavailability of a Hospital room by reason of capacity or distance or to any other circumstances beyond the control of the insured;
• Expenses for physiotherapy, if recommended by a Physician, for the Treatment of a specific Disablement and administered by a licensed physiotherapist; With regards to physiotherapy care, eligible charges up to $50.00 per visit, with a maximum of 10 visits.
• Dressings, drugs, and medicines that can only be obtained upon written prescription of a Physician.

The charges enumerated above shall in no event include any amount in excess of the Usual and Customary charges (as determined by the Company). To determine if Expenses are Usual and Customary, the Company will consider the following: the medical care or supplies usually given and the fees usually accepted for like cases in the area. "Area" means a region large enough to get a cross section of providers or medical care or supplies. All Expenses are deemed to be incurred on the date such service is received.

Emergency Dental Treatment (Accident)

Benefits are paid for Usual and Customary Expense for emergency Dental Treatment to natural teeth.

Emergency Dental Treatment (Palliative)

Benefits are paid for Usual and Customary Expense up to $100 for the emergency Treatment for the relief of pain to natural teeth.

Emergency Medical Evacuation & Repatriation

Benefits are paid for Covered Expense incurred up to $250,000. The decision for an Emergency Medical Evacuation or Repatriation must be pre-approved and arranged by the Assistance Company in consultation with Your local attending Physician. Emergency Medical Evacuation or Repatriation means: a) Your medical condition warrants immediate transportation from the place where You are located (due to inadequate medical facilities) to the nearest adequate medical facility where medical Treatment can be obtained; b) After being treated at a local medical facility, Your medical condition warrants transportation with a qualified medical attendant to Your Home Country to obtain further medical Treatment or to recover; c) Both a. and b. above. Non-Emergency use of special transportation is excluded from this plan.

Return of Mortal Remains

If You should die, Benefits will be paid for Expenses incurred up to $50,000 to return Your remains to Your Home Country. All Covered Expense in connection with a Return of Mortal Remains or Cremation must be pre-approved and arranged by the Assistance Company.

Emergency Medical Reunion

When it is determined that it is necessary and prudent for You to have an Emergency Medical Evacuation or Repatriation, this Plan will arrange to bring an individual of Your choice, from Your current Home Country, to be at Your side while You are hospitalized and then accompany You during Your return to Your current Home Country. Benefits will be paid up to $50,000 for reasonable travel and accommodation Expense up to a maximum of 10 days, as pre-approved and arranged by the Assistance Company.

Acute Onset of a Pre-Existing Condition Benefit

If the Plan Participant is a non-U.S. citizen, under age 70, traveling in the United States, he or she is covered for an Acute Onset of a Pre-existing Condition(s). This benefit does not apply to Plan Participants age 70 or older. Acute Onset of a Pre-Existing Condition(s) shall mean a sudden and unexpected outbreak or recurrence of a Pre-existing Condition(s) which occurs spontaneously and without advance warning either in the form of Physician recommendations or symptoms, is of short duration, is rapidly progressive, and requires urgent care. The Acute Onset of a Pre-existing Condition(s) must occur after the effective date of the policy. Treatment must be obtained within 24 hours of the sudden and unexpected outbreak or recurrence. A Pre-existing Condition that is a chronic or congenital condition or that gradually becomes worse over time will not be considered Acute Onset. This benefit does not include coverage for known, scheduled, required, or expected medical care, drugs or Treatments existent or necessary prior to the Effective Date of coverage.

Return of Minor Child(ren)

The Plan will pay for these services up to a maximum of $50,000 provided all transportation and services are pre-approved and arranged by the Assistance Company.

Interruption of Trip

If Your trip is interrupted due to one of the following reasons: 1) Death of an Immediate Family Member; 2) Serious damage to Your principal residence from fire, flood or similar Natural Disaster (tornado, earthquake, hurricane, etc.). Benefits will be paid up to $5,000 for the expense of economy return travel ticket to return you to your area of principal residence.

Political and Natural Disaster Evacuation

Coverage is provided up to $50,000 if the Insured requires emergency evacuation, which places him/her in Imminent Bodily Harm or due to a Natural Disaster, which makes his/her location Uninhabitable. The Assistance Company shall arrange, and the plan will pay for Insured's transportation to the nearest safe location. If evacuation becomes impractical due to hostile or dangerous conditions, the Assistance Company will maintain contact with and advise the Insured until evacuation becomes viable or the Natural Disaster situation has been resolved. Should commercial flights be available, but transportation to the airport will place the Participant in Imminent Bodily Harm, the Assistance Company shall arrange and pay for his/her secure transport to the airport. No benefit shall be payable if there is a travel warning in effect within 30 days prior to the insured person's date of arrival in the host country. The Assistance Company must make all arrangements for the Insured. Services rendered without the Assistance Company's coordination and approval is not covered. No claims for reimbursement will be accepted. Expenses for non-emergency transportation are the responsibility of the Participant.

In Hospital Indemnity (US Citizens only)

If You are a US citizen, traveling outside of the US, and confined to a Hospital as a registered Inpatient as the result of an Illness or Injury that is covered under this Plan, this plan will pay benefits up to $100 per day of confinement up to a maximum of 10 days to the covered Insured.

Unexpected Recurrence of a Pre-existing Condition (US Citizens Only)

The plan shall pay up to a maximum of $20,000 ($2,500 for age 65 and older) of Covered Expenses incurred from a sudden and unforeseen recurrence of a Pre-existing Condition. This does not include coverage for known, scheduled, required or expected medical care, drugs, or treatments existent or necessary prior to the Insured Person's effective date of coverage. Only such Medical Expenses which are incurred within 30 days from the date of recurrence of Illness, and which are not excluded will be considered Covered Expenses under this benefit. Note: This benefit is not available to Non-US citizens.

Loss of Baggage

This plan will reimburse You for loss, theft, or damage to Your baggage or personal effects, checked with a Common Carrier. This plan is secondary to any coverage provided by a Common Carrier and all other valid and collective insurance. $50 per article, to a maximum of $250.

Accidental Death and Dismemberment (AD&D)

If within 365 days after the date of a Covered Accident, the Insured Person's Injury results in death or dismemberment, this Plan provides the following benefits for loss of:

The amount of the Principal Sum is $25,000. If the Enhanced AD&D Benefit purchased, the $25,000 is included in the total benefit amount.

AD&D Disclaimer

The maximum AD&D benefit that can be selected is $100,000 of coverage, $25,000 if under 18 years of age.

Disappearance

If the body of an Insured Person has not been found within one year of the disappearance, forced landing, stranding, sinking, or wrecking of a conveyance in which such person was an occupant, then such Person shall have suffered loss of life within the meaning of the plan.

Paralysis Benefit

If a Covered Accident renders an Insured Person Paralyzed within 365 days of the date of the Covered Accident that caused the Injury, in any one of the types of paralysis specified below:

Coma Benefit

If a covered Injury renders an Insured Person Comatose within 90 days of the date of the accident that caused the Injury, and if the Coma continues for a period of 30 consecutive days, The Company will pay a monthly benefit of $250. No benefit is provided for the first 30 days of the Coma. The benefit is payable monthly as long as the Insured remains Comatose due to that Injury, but ceases on the earliest of: 1) the date the insured ceases to be Comatose due to the Injury; 2) the date the Insured dies; 3) the date the total amount of monthly Coma Benefit paid for all Injuries caused by the same accident equals $25,000.

Seat Belt and Airbag Benefit

The Company will pay a $25,000 benefit when the Insured Person suffers accidental death such that an Accidental Death benefit is payable under the plan and the accident causing death occurs while the Insured Person is operating, or riding as a passenger in an Automobile if: 1) You are wearing a properly fastened seat belt, properly installed by a factory authorized dealer; and 2) You were positioned in a seat protected by a properly functioning Supplemental Restraint System, properly installed by a factory authorized dealer that inflates on impact. This benefit is in addition to any other Expenses of the program.

Felonious Assault Benefit

The Company will pay a $25,000 benefit when an Insured Person suffers one or more losses for which benefits are payable under the Accidental Death & Dismemberment Benefit or Coma Benefit provided by the plan as a result of a Felonious Assault. Only one benefit is payable for all losses as a result of the same Felonious Assault. This benefit is in addition to any other Expenses of the program.

Home Alteration and Vehicle Modification

The Company will pay Covered Home Alteration and Vehicle Modification Expenses that are incurred within one year after the date of the accident causing such loss(es), up to a maximum of $2,500 for all such losses caused by the same accident.

WorldWide Assistance Services

After you enroll in the Diplomat Long Term you are eligible to use any of the assistance services provided by On Call International.

• Available 24 hours / 7 days a week
• Assistance with emergency Medical Evacuations and Repatriations
• Emergency Travel Assistance Services
• Referrals to Medical and Dental Providers Worldwide
• Multilingual personnel
• Doctors and nurses on staff

This is a limited benefit policy. The insurance described in this document provides limited benefits. Limited benefits plans are insurance products with reduced benefits intended to supplement comprehensive health insurance plans. This insurance is not an alternative to comprehensive coverage. It does not provide major medical or comprehensive medical coverage and is not designed to replace major medical insurance. Further, this insurance is not minimum essential benefits as set forth under the Patient Protection and Affordable Care Act.

The Plan Document does not cover any loss resulting from any of the following unless otherwise covered under the Plan Document by Additional Benefits:

1. Suicide, attempted suicide (including drug overdose) self-destruction, attempted self-destruction or intentional self-inflicted Injury while sane or insane;
2. War or any act of war, declared or undeclared; Unless War Risk Rider is purchased for travel outside the USA only;
3. Any Covered Loss which occurs while the Plan Participant is on Active Duty Service in any Armed Forces, National Guard, military, naval or air service or organized reserve corps;
4. Any Covered Loss sustained while in the service of the armed forces of any country. When the Plan Participant enters the armed forces of any country, We will refund the unearned pro rata premium upon request;
5. Voluntary, active participation in a riot or insurrection;
6. Medical expenses resulting from a motor vehicle accident in excess of that which is payable under any other valid and collectible insurance;
7. Medical Treatment related to organ transplants, whether as donor or recipient; this includes expenses incurred for the evaluation process, the transplant surgery, post operative treatment, and expenses incurred in obtaining, storing or transporting a donor organ. In relation to a bone marrow or stem cell transplant this exclusion would include harvesting & mobilization charges;
8. For any Covered Losses resulting from the Plan Participant's intoxication or use of illegal drugs or any drugs or medication that is intentionally not taken in the dosage recommended by the manufacturer or for the purpose prescribed by the Plan Participant's Physician;
9. Commission or attempt to commit an assault or felony, or that occurs while being engaged in an illegal occupation;
10. Eligible Expenses for which the Plan Participant would not be responsible in the absence of the Policy;
11. Treatment of acne;
12. Charges which are in excess of Usual, Reasonable and Customary charges;
13. Charges that are not Medically Necessary;
14. Charges provided at no cost to the Plan Participant;
15. Expenses incurred for treatment while in Your Home Country; except as provided under the Home Country Coverage Benefit;
16. Expenses incurred for an Accident or Injury or Sickness after the Benefit Period shown in the Schedule of Benefits or incurred after the termination date of coverage;
17. Regular health checkups; routine physical, immunizations or other examination where there are no objective indications or impairment in normal health;
18. Services or treatment rendered by a Physician, Registered Nurse or any other person who is employed or retained by the Policyholder; or an Immediate Family member of the Plan Participant;
19. Duplicate services actually provided by both a certified nurse midwife and Physician;
20. Any Covered Loss paid under Workers' Compensation, Employer's liability laws or similar occupational benefits or while engaging in an occupation for monetary gain from sources other than the Policyholder;
21. Benefits for enrolling solely for the purpose of obtaining medical treatment, while on a waiting list for a specific treatment, or while traveling against the advice of a Physician;
22. Aggravation or re-injury of a prior Injury that the Plan Participant suffered prior to his or her coverage Effective Date, unless We receive a written medical release from the Plan Participant's Physician;
23. Pre-existing conditions; (This exclusion does not apply to Emergency Evacuation/Repatriation or Return of Mortal Remains);
24. Treatment of a hernia, including sports hernia, whether or not caused by a Covered Accident;
25. Pregnancy or childbirth, elective abortion; elective cesarean section; or any complications of any of these conditions; pregnancy or childbirth of a dependent when dependent child of a Plan Participant;
26. 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;
27. Charges incurred for Surgery or treatments which are, Experimental/Investigational, or for research purposes;
28. Expense incurred for treatment of temporomandibular joint (TMJ) disorders or craniomandibular joint dysfunction and associated myofacial pain;
29. Dental care or treatment other than care of sound, natural teeth and gums required on account of Injury resulting from an Accident or emergency pain relief treatment to natural teeth while the Plan Participant is covered under the Policy, and rendered within 6 months of the Accident;
30. Eyeglasses, contact lenses, hearing aids braces, appliances, or examinations or prescriptions therefore;
31. Weak, strained or flat feet, corns, calluses, or toenails;
32. Private-duty nursing services;
33. The cost of the Plan Participant's unused airline ticket for the transportation back to the Plan Participant's Home Country, where an Emergency Medical Evacuation or Repatriation and/or Return of Mortal Remains benefit is provided;
34. Expenses payable under any prior policy which was in force for the person making the claim;
35. For the cost of a one way airplane ticket used in the transportation back to the Insured's country where an air ambulance benefit is provided and medically necessary;
36. Treatment paid for or furnished under any other individual or group policy, or other service or medical prepayment plan arranged through the employer to the extent so furnished or paid, or under any mandatory government program or facility set up for the treatment without cost to any individual;
37. Travel in or upon: (a) A snowmobile; (b) A water jet ski; (c) Any two or three wheeled motor vehicle, other than a motorcycle registered for on-road travel; (d) Any off-road motorized vehicle not requiring licensing as a motor vehicle; when used for recreation or competition. Unless the Hazardous Activity Benefit is purchased.
38. Injury sustained while taking part in: mountaineering; hang gliding; parachuting; bungee jumping; racing by horse, motor vehicle or motorcycle; snowmobiling; motorcycle/motor scooter riding; scuba diving, involving underwater breathing apparatus, water skiing; snow skiing; spelunking parasailing; white water rafting; surfing, unless part of a school credit course; and snowboarding. Unless the Hazardous Activity Benefit is purchased.
39. Practice or play in any amateur, club, intramural, interscholastic, intercollegiate, sports contest or competition. Unless Athletic Sports Rider is purchased.
40. Practice or play in any professional or semiprofessional sports contest or competition;
41. Rest cures or custodial care;
42. Treatment of Mental and Nervous Disorders;
43. Weight reduction programs or surgical treatment of obesity;
44. Treatment of venereal disease;
45. Elective or Cosmetic surgery and Elective Treatment or treatment for congenital anomalies (except as specifically provided), except for reconstructive surgery on a diseased or injured part of the body (Correction of a deviated nasal septum is considered cosmetic surgery unless it results from a covered Injury or Sickness);
46. Travel or flight in or on any vehicle for aerial navigation, including boarding or alighting from:
    • While riding as a passenger in any Aircraft not intended or licensed for the transportation of passengers; or
    • While being used for any test or experimental purpose; or
    • While piloting, operating, learning to operate or serving as a member of the crew thereof; or
    • while traveling in any such Aircraft or device which is owned or leased by or on behalf of the Policyholder of any subsidiary or affiliate of the Policyholder, or by the Plan Participant or any member of his household.
    • A space craft or any craft designed for navigation above or beyond the earth's atmosphere; or
    • An ultra light, hang-gliding, parachuting or bungi-cord jumping; Unless the Hazardous Activity Benefit is purchased.
    Except as a fare paying passenger on a regularly scheduled commercial airline or as a passenger in a non-scheduled, private aircraft used for business or pleasure purposes.
47. Ionising radiation or contamination by radioactivity from any nuclear fuel or from any nuclear waste, from combustion of nuclear fuel, the radioactive, toxic, explosive or other hazardous properties of any nuclear assembly or nuclear component of such assembly.
48. Plan Participant being exposed to the Utilisation of nuclear, chemical or biological weapons of mass destruction.
49. Treatment of HIV infection, HIV related illness and AIDS (acquired immune deficiency syndrome) in excess of a lifetime maximum of $7,500;
50. Expenses incurred for services, testing and treatment of Sleep Apnea.

In addition to any of the exclusions listed above, for Eligible Expenses under Trip Interruption, this Insurance also does not cover the following:

1. The Plan Participant or Traveling Companion or Traveling Companion's family making changes to personal plans; having business or contractual obligations; being unable to obtain necessary travel documents (passports, visas, etc.); being detained or having property confiscated by customs authorities; carrier caused delays (including bad weather);
2. Prohibition or regulatory by any government; default of yacht charter companies; default of the organization from which the Plan Participant purchased their trip arrangements;
3. A Pre-Existing Condition existing prior to the Plan Participant's departure from their Home Country.

In addition to any of the exclusions listed above, for Eligible Expenses under Baggage Loss, this Insurance also does not cover the following:

• Animals;
• Artificial teeth or limbs, hearing aids;
• Sunglasses, contact lenses or eyeglasses;
• Professional or occupational equipment or property, whether or not electronic business equipment or;
• Telephones or PDA devices, computer hardware or software;

Jurisdiction Limitation

Coverage is not available for residents of Australia or Iran or residents of New York, Maryland and South Dakota. Coverage is not available for travel in Afghanistan, Cuba, Iran, Israel, Nepal, or Palestinian Territories.

Refund of Plan Cost

A refund of the plan cost, less a $25 processing fee, will be considered only when written request is received by the administrators prior to the Effective Date of Individual coverage. After the Effective Date of Individual coverage, the plan cost is considered fully earned and non-refundable. Partial refunds are not available.

Excess Benefits

All Coverage, except Accidental Death & Dismemberment, shall be in excess of all other valid and collectible insurance.

Subscription Agreement - I hereby apply to be a Plan Participant of the Fairmont Specialty Trust (the "Trust") and to participate in the insurance coverage extended by certain underwriters at Crum & Forster, SPC ('the Insurers') to Plan Participants under the Trust (the "Coverage"). I understand that the Coverage is not a general health insurance product, but is intended for use in the event of a sudden and unexpected event while traveling outside my Home Country. I understand that the Coverage extended to me will terminate upon my return to my Home Country unless I qualify for a Benefit Period or Home Country Coverage. I understand that I may obtain full details of the Coverage by requesting a copy of the Master Policy from the Plan Manager. I understand that the liability of the Insurers as underwriters of the Coverage is as provided in the Master Policy. By acceptance of coverage and/or submission of any claim for benefits, the Plan Participant ratifies the authority of the signer to so act and bind the Plan Participant. The Plan Participant undertakes to make all premium payments as they fall due in respect of the Coverage extended to them. The Trustee shall not be responsible for the administration of such payments. If the Plan Participant fails to make any premium payment due in respect of the Coverage extended to them, subject to the discretion of the Insurance Company, such Coverage will lapse. The Plan Participant hereby confirms the accuracy of all information validity of all representations and warranties provided to the Trustee in connection with its participation in the Plan and/or the subscription for the insurance coverage, howsoever provided, including the terms of this Subscription Agreement, (together "Representations & Warranties"). The Plan Participant acknowledges that certain of such information will be relied upon by the Insurers as providers of the Coverage and that any inaccuracy therein may result in the invalidity of such Coverage as it relates to the Plan Participant, the loss of Coverage and all monies paid in relation thereto. The Plan Participant hereby undertakes to inform the Trustee of any change to any of matter that forms the subject of any of the Representation & Warranties. The Plan Participant hereby undertakes to indemnify and hold harmless the Trustee against any loss or damage (including attorney's fees) occasioned by any inaccuracy in any Representation & Warranty or failure to advise the Trustee of any change in any matter that forms the subject of any of the Representation & Warranties. The Plan Participant agrees that the Trustee shall be entitled to rely on and to act in accordance with any written instruction purported to be provided by the Plan Participant and the Plan Participant hereby undertakes to indemnify and hold harmless the Trustee against any loss or damage (including attorney's fees) occasioned by the Trustee acting in accordance with any such instruction. Payments under the terms of the Coverage shall be paid by the Insurers to the Plan Participant or directly to a provider if assignment of benefits has been authorized. The Trustee shall not be responsible for the administration of such payments. I confirm that I have satisfied myself that the coverage is appropriate for me and that I meet the eligibility criteria.

Complaints - In the event that You are dissatisfied and wish to make a complaint You can do so to the Complaints team at Global Claims Administration at 1-800-513-2981 or 513-533-1330.

Please keep this Evidence of Coverage as a general summary of the insurance as specified in the Plan Document issued to and on file with Diplomat LT. The Plan Document contains a complete description of all of the terms and conditions including: the benefits, provisions, exclusions of the insurance plan as underwritten by Crum & Forster, SPC. The Plan Document will prevail in the event of any discrepancy between this Evidence of Coverage and the Plan Document.

Benefits are provided for eligible Insured Persons. Terms and conditions are briefly outlined in this brochure. This plan contains both insurance and non-insurance benefits. Complete provisions pertaining to the insurance portion of the plan are contained in the policy. In the event of any conflict between this brochure and the policy, the policy will govern. The policy is a short-term limited duration policy renewable only at the option of the insurer. This is a brief description of the important features of your plan. It is not a contract of insurance. The terms and conditions of coverage are set forth in the Plan. For a detailed plan description, exclusions, and limitations please view the plan on file with the administrator. This insurance is not subject to, and will not be administered as a PPACA (Patient Protection and Affordable Care Act) insurance plan. PPACA requires certain US residents and citizens obtain PPACA compliant insurance coverage. This policy is not subject to guaranteed issuance or renewal.

Traveling to the United States

Traveling Outside the United States

Diplomat LT must be purchased for a minimum of 3 months, the maximum is 365 days. Renewal coverage may be purchased for up to 365 days at a time, to a maximum of 3 years.

War Risk Coverage

For travel Outside of the USA and the insured's home country, you may get an instant quote online or by calling us for a quote.

Total AD&D coverage includes the $25,000 base amount.

Home Country Coverage Benefit (Not available for those age 80 or older)

Provides limited coverage under Your Medical Expense Benefit while in Your Home Country. The plan pays 80% up to $5,000 of Covered Expenses, then 100% to a maximum of 1) $50,000 for Incidental Trip(s) to your Home Country or 2) $10,000 for Extension of Benefits (Follow Me Home Coverage). (Apply 1.10 factor to your total premium)

Athletic Sports & Hazardous Activity Benefit

provides coverage if Your Injury or Illness results from the below enumerated Athletic Sports & Hazardous activities. NOTE: Any Athletic Sport & Hazardous Activity not expressly covered hereunder is excluded from this policy unless the activity is approved by the company prior to purchase or the activity is non-contact and engaged in by You solely for leisure, recreation, entertainment, or fitness purposes only.

Table 1: For the below listed activities apply the 1.25 factor to the base premium:

(1) Low Option

BMX; Bobsledding; Bungee Jumping; Canoeing/Kayaking; Canopying; Cave tubing; Hang Gliding; Horseback Riding; Hot Air Ballooning; Jet Skiing; Martial Arts/Karate (Non-competitive); Motor Scooter; Motorcycling; Mountain Biking; Piloting any Non-commercial Aircraft; Safari; Scuba Diving (Not to exceed 30 feet, Resort Course or equivalent required); Snow Skiing (Recreational); Snowboarding (Recreational); Snowmobiling; Spelunking/Caving; Surfing (Recreational); Trekking (Not exceeding Class IV Difficulty on Yosemite Decimal System); Wakeboarding; Water skiing; Whitewater Rafting (Class I through V rapids); Wind Surfing; Zip Lining.

For the below listed activities apply the 1.25 factor to the base premium plus the monthly flat rate listed:

(2) Middle Option- Additional $25.00 flat monthly rate

Aerial Photograph (Use of proper restraints required); BMX (Racing or Competitive); Flying in any chartered/leased aircraft or helicopter; Heli-skiing; High Diving; Hot Air Ballooning (As a pilot); Mountain Climbing (14,000 ft. & below - Ropes & proper safety equipment required); Parachuting; Paragliding; Parasailing; Parascending; Rock Climbing (Ropes & proper safety equipment required); Scuba Diving (Below 30 feet, PADI/NAUI Certification required, or insured must be accompanied by a certified diving instructor); Skydiving; Snow Skiing Off-Piste.

(3) High Option - additional $50.00 flat monthly rate

Big Game Hunting (Use of Firearms); Diving with Sharks; Mountain Climbing (14,000 ft. & above - Ropes, proper safety equipment & certified guide required); Running with the Bulls; Security Detail (use of firearms).

Table 2: For the below listed Intercollegiate, Interscholastic Athletics, Club Sports, and Organized Amateur Sports, apply the 1.25 factor to the base premium plus the monthly flat rate listed.

Under this enhancement, the Benefit is reduced to $20,000 for any Covered Injury or Illness resulting from:

(1) Low Option - additional $12.00 flat monthly rate

Ballet; Baseball; Cheerleading; Cross Country; Diving; Equestrian; Fencing; Field Hockey; Golf; Polo (Horse); Polo (Water); Rowing; Softball; Surfing; Swimming; Tennis; Track & Field; Volleyball.

(2) Middle Option - additional $26.00 flat monthly rate

Basketball; Competitive Cycling (Road, Track, CX); Ice Hockey; Inline Skating (Helmet & Proper Equipment Required); Lacrosse; Martial Arts/Karate; Modern Pentathlon; Skiing (Slalom, Giant Slalom, Downhill); Ski Jumping; Wrestling.

(3) High Option - additional $80.00 flat monthly rate

Football (No Division One); Gymnastics; Rugby (No Division One); Soccer.

FOR ADDITIONAL INFORMATION

Phone: +1-5086735893
Fax: +1-5086770792
Website: stafford.brokersnexus.com

Version: 6-2024