| Schedule of Benefits and Limits |
| Deductibles |
$0, $100, $250, $500, $1,000 or $2,500 per Certificate Period |
| Coinsurance - Claims incurred in US or Canada |
For the Certificate Period, Underwriters will pay 80% of the next $5,000 of Eligible Expenses after the Deductible, then 100% to the Overall Maximum Limit |
| Coinsurance - Claims incurred outside US or Canada |
For the Certificate Period, Underwriters will pay 100% of Eligible Expenses after the Deductible up to the Overall Maximum Limit |
| Hospital Room and Board |
Average semi-private room rate, including nursing services |
| Local Ambulance |
Usual, Reasonable and Customary charges |
| Hospital Indemnity |
$100 per day (not subject to Deductible or Coinsurance) |
| Intensive Care Unit |
Usual, Reasonable and Customary charges |
| Outpatient Treatment |
Usual, Reasonable and Customary charges |
| Acute Onset of Pre-Existing Condition |
$15,000 limit per Certificate Period for Eligible Medical Expenses
$25,000 limit per Certificate Period for Emergency Medical Evacuation (only available to US Citizens under age 70) |
| Physical Therapy |
$50 per visit |
| All Other Eligible Medical Expenses |
Usual, Reasonable and Customary charges |
| Emergency Dental |
Accident - Overall Maximum Limit
Acute Onset of Pain - $100 limit per Certificate Period |
| Emergency Medical Evacuation |
Overall Maximum Limit |
| Emergency Reunion |
$15,000 limit per Certificate Period |
| Return of Minor Children |
$5,000 limit per Certificate Period |
| Terrorism |
$50,000 Maximum Lifetime Limit, Medical Expenses only |
| Accidental Death and Dismemberment |
Principal Sum
$25,000 Adults age 18-69
$12,500 Adults age 70-74
$ 6,250 Adults age 75 and above
$ 5,000 Children age 17 and below |
| Common Carrier Accidental Death |
$50,000 per adult, $25,000 children under age 18; $250,000 Maximum per family |
| Repatriation of Remains |
Overall Maximum Limit |
| Natural Disaster Benefit |
Up to $100 a day for 5 days when Displaced from planned, paid accommodations due to evacuation from forecasted disaster or following a disaster strike |
| Trip Interruption |
$5,000 limit per Certificate Period |
| Lost Checked Luggage |
$250 limit per Certificate Period (not subject to Deductible or Coinsurance) |
| Hospital Pre-Notification Penalty |
50% of Eligible Medical Expenses |
| Optional Hazardous Sports Rider |
Overall Maximum Limit |
| Overall Maximum Limit per Certificate Period (includes all benefits except Accidental Death and Dismemberment and Common Carrier Accidental Death) |
Age 14 days to 69 - $50,000, $100,000, $250,000, $500,000 or $1,000,000
Age 70 to 79 - $50,000
Age 80 or older - $10,000 |
