Patriot America Insurance

Patriot America^SM provides coverage for non-US citizens traveling outside their country of citizenship for a minimum of 10 days up to a maximum of one year.

Although the Patriot America Insurance plan is not renewable, it can be rewritten for succeeding or subsequent coverage periods. New deductible, coinsurance, eligibility, conditions of coverage and pre-existing condition exclusions apply to any succeeding or subsequent Period of Coverage. A new application also must be completed. If you or other family members applying for coverage are age 65 or older, please see the eligibility section of the Patriot brochure for additional information.

If you are a non-US citizen traveling for three (3) months or more and under age 70, please review the ExPatriot Plus® plan, which offers a 10% discount on rates and is renewable for up to two years.

ONE MONTH RATES (four Policy Maximum options)
	Option 1	Option 2	Option 3	Option 4
	$50,000	$100,000	$500,000	$1,000,000
AGE	One Month	One Month	One Month	One Month
18-29	$48	$56	$72	$84
30-39	$62	$74	$94	$108
40-49	$94	$106	$140	$158
50-59	$134	$164	$198	$228
60-64	$158	$194	$230	$276
65-69	$180	$232	$252	$300
70-79	$244	N/A	N/A	N/A
80+*	$424	N/A	N/A	N/A
DEP. CHILD	$28	$32	$40	$44
CHILD ALONE	$44	$52	$66	$74
*US$10,000 limit

DAILY RATES (MINIMUM COVERAGE IS 10 DAYS)
	Option 1	Option 2	Option 3	Option 4
	$50,000	$100,000	$500,000	$1,000,000
AGE	Daily	Daily	Daily	Daily
18-29	$1.60	$1.90	$2.40	$2.80
30-39	$2.10	$2.50	$3.15	$3.60
40-49	$3.15	$3.55	$4.70	$5.30
50-59	$4.50	$5.50	$6.60	$7.60
60-64	$5.30	$6.50	$7.70	$9.20
65-69	$6.00	$7.75	$8.40	$10.00
70-79	$8.15	N/A	N/A	N/A
80+*	$14.15	N/A	N/A	N/A
DEP. CHILD	$0.95	$1.10	$1.35	$1.50
CHILD ALONE	$1.50	$1.75	$2.20	$2.50
*US$10,000 limit

All premium rates are in US dollars and are effective through 12/31/2004. Rates include 2.5% surplus lines tax. A dependent child is your child shown on the Application Form over 14 days and under 18 years of age, traveling with you, and for whom premium has been paid.

Refund of Premium

IMG will refund premium only if a written request is received prior to the certificate's effective date. The premium is non-refundable after that date.

Precertification, Emergency Evacuation and Repatriation

For precertification, emergency evacuation and repatriation please call IMG in the U.S. 1-800-628-4664 (toll free) or 1-317-655-4500. Call IMG outside the US: 001-317-655-4500 (collect if necessary). This information will also be provided on your ID card.

IMG must be notified prior to treatment or within 48 hours of an emergency.

To Report Claims

Please mail completed claim forms to International Medical Group, 407 Fulton Street, Indianapolis, IN 46202 USA. All IMG contact numbers, claim forms and Policy Wordings will be included in the fulfillment kit. IMG may also be contacted by fax: 317-655-4505 or email: insurance@imglobal.com.

This web page contains only a consolidated and summary description of all current Patriot Travel Medical Insurance benefits, conditions, limitations and exclusions. A certificate containing the complete Policy Wording with all terms, conditions and exclusions will be included with the fulfillment kit. IMG reserves the right to issue the most current Policy Wording for this insurance plan in the event this application and/or brochure has expired, is modified, or is replaced with a newer version. Current Policy Wordings are available upon request.