The Beacon Series Group Travel Medical Plan

Council for Educational Travel Worker I Trainee I Intern Program

Policy #A92355005

Prepared by your Insurance Broker: Capistrano Insurance Services Inc. 8780 19th Street #346 Rancho Cucamonga, CA 91701 Tel: (909) 472-3300 Fax: (909) 472-3310

Distributed & Administered by: Azimuth Risk Solutions, LLC 55 Monument Circle, Suite 1128 Indianapolis, IN 46204 Tel: (888) 201-8850 Fax: (888) 201-8851

..::(~._.~. r -.1 t_~"-~;

ti

~':

(U5K sO{lfT(6~
EVIDENCE OF INSURANCE THE BEACON SERIES GROUP TRAVEL MEDICAL PLAN This Evidence of Insurance is issued by the Master Policy on behalf of the Master Policyholder, as so authorized by Certain Underwriting Members at Lloyd's who have hereunto subscribed their Names ("The Underwriters") to this Evidence of Insurance and the Master Policy; the Beacon! Axis Series Group Insurance Trust (Anguilla). As such certain Underwriters at Lloyd's authorize Azimuth Risk Solutions, LLC. as the ("Scheme Administrator") of the Master Policy and all Evidence{s) of Insurance issued by the Master Policy. THIS DOCUMENT (EVIDENCE OF INSURANCE) IS ISSUED AS NOTICE OF INSURANCE FOR INFORMATION ONLY. THIS EVIDENCE OF INSURANCE DOES NOT CONSTITUTE A LEGAL CONTRACT OF INSURANCE. THE CONTRACT IS THE MASTER POLICY (HELD BY THE MASTER POLICYHOLDER), THE APPLICATION, AND ANY APPLICABLE RIDER{S). THIS EVIDENCE OF INSURANCE IS FURNISHED IN ACCORDANCE WITH, AND IN ALL RESPECTS IS SUBJECT TO, THE TERMS AND CONDITIONS OF THE MASTER POLICY. THIS EVIDENCE OF INSURANCE REPLACES ANY OTHER EVIDENCE OF INSURANCE PREVIOUSLY ISSUED COVERING THE INSURANCE DESCRIBED HEREIN. PLEASE REFER TO YOUR APPLICATION FOR DETAILS ON THE SELECTED COVERAGE AMOUNTS AND DEDUCTIBLES. This insurance is provided under the Master Policy and is in accordance with the Terms and Conditions of the Master Policy. The Master Policy is available upon request at any time by contacting the Scheme Administrator at seryl~@.!lJmuthrisk.J:om or by calling LIS at (317)644-6291 (we accept collect calls) or (888)201-8850. 1. 2. 3. 4. 5. 6. Master Policy Number: A92355005 Name of Master Policyholder: Beacon! Axis Series Group Insurance Trust (Anguilla). PartiCipating Member: All partlcipants enrolled in the Beacon/Axis Series Group Insurance Trust (Anguilla); under the Beacon Series Travel Medical Insurance Plan. Scheme Administrator: Azimuth Risk Solutions, LLC. 55 Monument Circle, # 1128, Indianapolis, Indiana 46204, United States of America. Coverage Period: The coverage period will be that in which is shown on the Declaration Page issued at the time of approval. Cancellation: All cancellation requests must be submitted in writing to the Scheme Administrator. To be eligible for a full refund, the request must be received prior to the requested effective date of coverage. Cancellation requests received after the requested effective date will be subject to the following: a. A $25.00 cancellation fee; and b. Only the unused portion of the premium cost will be refunded; and c. No claims to be eligible for premium refund. Filing a Claim: Notice of Claim should be submitted to: Korak Healthsource, Inc. c/o Azimuth Risk Solutions, LLC. P.O. Box 206, Forest Hill, MD 21050. The following items must be submitted to be considered a complete Proof of Claim eligible for consideration of payment: a. A duly completed and signed Claim Form; and b. All original itemized bills from all Physicians, Hospitals and other healthcare or medical service providers involved with respect to the claim; and c. All original receipts for any expenses that have been incurred or paid by or on behalf of the Participating Member(s) with respect to the claim(s).

7.

The Participating Member shall have ninety (90) days from the date the claim is incurred to submit a complete Proof of Claim to the Scheme Administrator. The Scheme Administrator may deny coverage for any Proof of Claim submitted thereafter or for incomplete Proofs of Claims. All Claim decisions made by the Scheme Administrator or on behalf of the Scheme Administrator are with the express consent of the Underwriters.

Schedule of Benefits/limits:
Subject to the Terms of this insurance, including without otherwise expressly set forth to the contrary), and various Administrator promises to provide the Participating Member Injury or Illness incurred while this Evidence of Insurance is in limitation the Deductible and Coinsurance (unless limits and sub-limits set forth below, the Scheme the following benefits and coverage arising out of effect:

04-EOI-09-BTI

The Beacon Series Group Travel Medical Plan Schedule of Benefits

Maximum Deductibles Limits $250,000 $100 per Coverage Period The plan pays 80% of next $5,000 of Eligible Expenses, then 100% to the overall Maximum Limit for claims incurred in the US or Canada. (The Coinsurance is waived if incurred in the US and within the Multi-Plan PPO). Plan pays 100% for claims incurred outside the US & Canada. 50% $150 per night; Inpatient Hospitalization (Outside the US & Canada) Average Semi-private room rate. Usual, Reasonable and Customary to selected Policy Maximum Limit. Usual, Reasonable and Customary charges, when covered Illness or Injury results in Hospitalization as Inpatient. $60 Maximum Limit per visit. Maximum 15 visits. Condition $20,000 Maximum Limit for Eligible Medical Expenses. Including Emergency Medical Evacuation (US Citizens Only). $1,000 Maximum Limit for Eligible Medical Expenses (all others). Usual, Reasonable and Customary Charges.
for 90 days or

Coinsurance

(Subject to Deductible)

Pre-Certification

Penalty

Hospital Indemnity Hospital Room & Board Intensive Care Unit Local Ambulance Physical Therapy Sudden Onset of Pre-existing All Other Medical Expenses Dental (Injury as result of Accident)
Only available for Policies purchased more.

$250 Maximum Limit per Coverage Period. $150,000 Maximum Limit $15,000 Limit per Coverage Period $30,000 Limit per Coverage Period $5,000 Limit per Coverage Period

Emergency Emergency

Medical Evacuation Reunion

Return of Mortal Remains Return of Minor Children Quick Trip Home Country Home Country (End of Trip) Coverage Coverage

14 days cumulative Home Country Coverage (as defined by Policy). Subject to a Minimum 3 month purchase. Free 15 days with a 6 month purchase, or Free 30 days with a 12 month purchase per Coverage Period. $250 per Coverage Period (not subject to Deductible or Coinsurance). in the Policy. As defmed

Lost Checked Luggage Accidental Death & Dismemberment (AD&D) Common Carrier Dismemberment Terrorism Trip DelaylMissed Connection Personal Liability Accidental Death &

$30,000 for Insured or Insured spouse and $6,000 for Dependent Child(ren) $50,000 per Member (age 18 and over) $30,000 per Member (under age 18) $50,000 Maximum Limit, Medical expenses only. Maximum Limit of$100 a day after a minimum of 12 hour delay period. As defmed in the policy. $500 per Coverage Period $150,000 Maximum Limit personal liability and damage to property.
Member equals the above Limit

Third Party Liability-

Third Party Liability- Damage to Property

The Aggregate Limit for the Personal Liability Coverage per Participating

Frequently Asked Questions:

1. Who is Azimuth Risk Solutions? Azimuth Risk Solutions is the Managing Agency for Lloyds of London. From a participant prospective, they provide claims and provider services. 2. What if I am sick, how do I see a doctor? Please go to the MultiPlan website, http://bit.lv!multi-plan, and choose either Doctor or Facility. Enter search criteria and a list of doctors or facilities will be provided to you. If making an appointment with a doctor, please call the doctors office to make an appointment. 3. What is a deductible? The deductible is the amount you are responsible to pay during a policy period. deductible per coverage period.

This policy has a $100 policy

4. What if there is not a provider in my area? MultiPlan has more than half a million healthcare providers under contract and in the event that there is no network provider in the area, Azimuth will work with the individual regarding the co-insurance. 5. How do I file a claim? In some cases a doctor may request that payment be made therefore you must send in a claim form for reimbursement. To do so, please complete the attached claim form and mail the claimform and all original itemized bills to: Azimuth Risk Solutions, LLC 55 Monument Circle, Suite 1128 Indianapolis, IN 46204 6. Is there an emergency claims number? Yes, that number is (888) 201-8850 and press option 9. For participants outside of the US, please call collect (317) 644-6291. 7. What is the difference between and In-Network provider and a Out-of-Network Provider? Azimuth has a network of medical providers which are a part of a PPO network called Multiplan with whom they have negotiated discounted medical rates and these are considered "In Network". If a provider isn't part of the PPO network then they are deemed "Out of Network". 8. What if! have an emergency? If you should have an emergency, please go to the hospital. Emergency hospital admissions must be reported within 48 hours by either the participant, provider or family member. Failure to comply may result in a reduction of benefits.

What is not covered?

Charges related to: Preexisting Conditions - Except for Sudden Onset of Pre-existing Condition, charges resulting directly or indirectly from or relating to any Pre-existing Condition are excluded from coverage under this insurance. Pregnancy - Charges related to Pregnancy, including but not limited to pre-natal care, child birth, postnatal care, false labor, edema, prolonged labor and/or prescribed rest during the period of pregnancy, including newborn care. Experimental treatments or surgery Weight modification treatment, plastic surgery unrelated to restoration after a covered injury or illness or sex -change surgery. Injuries as a result of engaging in Hazardous Sports without the purchase of the Optional Sports Rider. Any injury or illness as a result of the consumption of alcohol or drugs; or for the treatment of substance abuse.

This is a partial list and description of exclusions. For a full description, please contact Capistrano Insurance Services at (909) 472-3300 or by email atinfo@capistrano-ins.com.

RISK

,~ .. ~,-. SOLUTIONS
'

,.

Claim Form
Please complete Parts 1,2/3,4, and 51 if applicable. Mail all claim forms and all original itemized bills for services and supplies to: Azimuth Risk Solutions, LLC 55 Monument Circle Website: www.azimuthrisk.com E-mail: slarv!ce.@Elziliii'!J,ttRw!s!l(,~~m

Suite 1128
Indianapolis, IN 46204

Phone: 317-644-6291/888-201-8850
Fax: 317-423-9620/888-201-8851

For any additional questions or concerns please contact us via e-mail, fax, or phone.
Part 1 Please complete claim form below. All communications of this claim will be sent to the address below. Is this claim related to (please check one): [J Dental [J Illness/Injury Accident [JAccident Related Injury Claimant/Patient Name: Date of Birth:
M/D/Y

Policy holder's Name:

I [JMale [JFemale

Date of Birth: City, State:

M/D/Y

[JMale [JFemale Country: Postal Code:

Complete Mailing Address for all correspondence:

Email: Destination Country(ies): Identification Number: Full-Time Student: 0 Yes ONo

I Telephone:

I Work Telephone:

I Citizenship of Claimant:

I Home Country:

If yes, please provide the name and address of the school: Is this a continuing claim? Please check here: 0 Yes 0 No If yes, please provide original dates of the initial claim

form

sent:

Part 2 If covered by another insurance plan pleasecomplete below. Do you have additional Insurance? 0 Yes [J N 0 Name of Primary Insured of other insurance company: Pleaseprovide name of other insurance company: Mailing address of other insurance company: Policy Number of other insurance plan:

I Date of Birth: I Group Number of other insurance plan:

M/D/Y

Part 3 Please fill out all applicable questions

below, more information (If you need additional space, please attach a separate sheet.) begin?

may be requested.

1. How did this condition/illness

Please describe all symptoms.

2. 3. 4.

When did the first symptom of the illness/condition Have you ever been treated for this illness/condition

begin?

(M/D/Y)

before? aVes aNo

List all the names and addresses of the providers you have seen for this illness/ condition:

5.

Is this illness/condition

the result of an accident?

aVes aNo

6.

Is this illness/ condition related to a work accident? If yes, have you applied for workers compensation?

aVes (JNo (JVes (JNo

7.

Did this illness/condition involve a motor vehicle? aVes aNo If yes, please provide names of all parties involved, including insurance carriers and policy numbers including the dates of accident:

8.

Was a police report filed? aVes (JNo If yes, Name and Number of Police Department, and number of report:

Part4

Please complete only if treatments

ConcfItion(s)/DiaQnosis

occurred outside of the US.

Physidan/Hospital/Clinic/Healttl Care Provider Name(s), Address 8t Telephone

Country which treabnent occurred in?

Dat.e(s)of Treatment

Total Charge paid/billed?

Type of culTel1CY
paid/billed?

PartS Authorization, please complete for all daims.

I vaify aDirformaI:K:n cnntaine::l in this foon is true, a:xTErt am a:rrpIete to the te;t eX my kn::lwIa:tJe.

The IIImsiYiled cUhoiizes any dodDr, medc:aI practtionE!l, hospiIaI,.di1ic:, heaIh faciIly, pha!macy, gcM!mment agenc.y, i1sI.IIanoe agenc.y, i1sI.IIanoe ml'npany, group policyholder, or insI.IIante or beneIi: admirdstiatDi or any other enII.y hailing irloonation as to the ~ ~ tleat:n1E!J1l;. ~ or physical or mental mlleition d any family member isted on this Applicationto release said iriom1ation to Azimuth RiskSoUions, LLC.
1Ittte: My false staIB
I lei It, ~

crfiau:! 5001rerderthis irs..rarK:e nuBard 'AX! ard daim; here..rder sMl be fofeiB:I. ~ eX sevk:es ~ the attached bIIs. Dale{Mo./DaV/Yr.)

Aut!0 izatb I: I aIAtnize J'EYITffiI: eX m:DcaI talEfis to the d:x:JIra-dher Print Name of Primary Insured,

Signature of Insured, Or Guardian,

Date{Mo./DaV/Yr.)