EFTA00317280

Global Assistance Karyna Shuliak Thank you for your recent purchase of Allianz Travel Insurance. We are pleased that you have chosen to take us along on your upcoming trip! This packet of information will help you use your travel insurance policy and includes: • A summary of assistance services and benefits described below • Your Letter of Confirmation of insurance benefits • Your detailed Certificate of Insurance/Policy Summary of Assistance Services and Benefits You are entitled to important assistance services and benefits. Service/Benefit Concierge 24-Hour Hotline Assistance To make the most of your assistance services and benefits please: • Read the detailed Certificate of Insurance/Policy. • Download the TravelSmart app for a listing of hospitals and clinics for your destination(s) available at both the App Store and Google Play. • If you require emergency medical care while traveling, please call our office for assistance before engaging any expense. • Save or photograph all receipts in the event you need to file a claim. Claims may be electronically filed at www.allianztravelinsurance.com EFTA00317280 Allianz Letter of Confirmation August 26. 2015 Name: ICa na Shuliak Policy No.: Kan na Shuliak i Dear Karyna Shuliak, Emergency Assistance Card For emergency assistance during your trip call: 1-888-358-2754 1-804-281.5700 (From U.S.) (Outside the U.S.) I (Collect) Thank you for choosing Allianz Global Assistance to protect your travel investment. For benefit information call: 1-888458-2754 Please make sure you read this Letter of Confirmation, your enclosed Policy, and (From U.S.) any other attached documents, including riders or other farms carefully. Because the Policy may describe coverage not included in your plan, be sure to look at all of To modify your policy or file a claim, please visit: the documents to understand your specific coverage. Contact us immediately if you www.allianztravelinsurance.com think there is a mistake in your Letter of Confirmation. 9950 Mayland Drive. Richmond. VA 23233 This Letter of Confirmation and the enclosed Policy contains important information on the insurance plan you purchased. Your plan includes the following coverage. up to the limits shown. Please see your Policy for information about how We recommend that if you are traveling for your event, you take copies of these our insurance works. documents with you. If you did not receive a Policy. or would like another copy, please call 1-800-284-8300. Coverage Benefit Limits* Information About Your Plan Baggage Coverage $1,000.00 Name of your plan: Annual Executive Plan Baggage Delay Coverage $1,000.00 Policy identification number. Business Equipment Coverage $1,000.00 Number of people insured: 1 Business Equipment Rental Coverage $1,000.00 Who it insures: Karyna Shuliak Change Fee Coverage $250.00 Date of purchase: August 26, 2015 Emergency Medical Transportation $250,000.00 Plan effective date: August 27, 2015 - August 27, 2016 Emergency Medical and Dental $50,000.00 Travel dates: Trip Cancellation Protection $5.000.00 Total cost for all travelers: $459.00 Travel/Trip Delay Coverage $1,500.00 Amount paid: $459.00 Trip Interruption Protection $5,000.00 Travel Accident Coverage $50.000.00 Changes to your travel plans may require changes to your coverage. If your plans 'USD per person urress noted otherense change please contact Allianz Global Assistance. Please Note Thanks again for purchasing a travel insurance plan from Allianz Global Assistance. • If your policy includes Trip Cancellation/Trip Interruption, Have a safe and pleasant trip! these benefits are per policy per year. Additional travel insurance. on a per trip basis. may also be purchased Sincerely, when booking your next trip. • Emergency Medical and Dental Benefits are primary. • For Emergency Medical and Dental benefits there is no deductible. • There is a $500 maximum for all covered dental Mark Henson expenses. Vice President of Travel Operations AGA Service Company • AGA Service Company is the licensed producer and administrator for this plan. • Insurance coverage is provided under Form No. To modify your policy or file a claim, please visit: www.allianztravelinsurance.com 52.201.401.NY PC and 52.201.008.NY AH issued by BCS Insurance Company. Form No. 52.201.LOC.02.NY PC 1Form No. 52.201.LOC.02.NY AH EFTA00317281 TI_BCS_LOCy_400_003_NY ' TI_BCS2101_032_,NY_V2S " 52_201_OE_01 ' BCSPRIVNOT EFTA00317282 INSURING CLAUSE Part I. EFFECTIVE DATE BCS Insurance Company, herein referred to as the Company. Coverage Term: The Coverage Term shall start at 12:01 A.M. will pay You the insurance benefits described in this Policy. on the date shown on Your Letter of Confirmation, subject to Allianz Travel Insurance Please refer to the accompanying Letter of Confirmation. It payment of the premium due. The Coverage Term ends at provides You with specific information about the plan You 12:01 A.M. on the 366th day after the date the Coverage Term purchased. Please contact Us immediately if You believe that starts. the Letter of Confirmation is incorrect. Individual Travel Effective Date: The Trip Cancellation coverage is in effect for each Trip made during the Coverage Term. Other insurance Insurance Policy RENEWAL CONDITIONS This Policy is issued for a single term and is non-renewable. coverages are in effect during each Trip made during the Coverage Term, effective on each Trip's Scheduled Departure Date and upon Your leaving your residence, place of employment, lodging or other location from which You directly PLEASE READ THIS POLICY CAREFULLY FOR FULL start Your Trip. FOR SERVICE, VISIT OR CALL: DETAILS. This Policy is a legal contract. The entire contract consists of No coverage is in effect for any Trip that is made by mass www.allianztravelinsurance.com transit, taxi, limousine service, personal automobile, bus, this Policy: any Endorsements or Riders attached to it; and the 1-800-284-8300 Letter of Confirmation. Capitalized words are defined terms. commuter rail or airline service, including inter-urban rail Please see the Definitions section. service by Amtrak unless the Trip is scheduled: 1. to take You at least 100 miles from Your residence, place FOR EMERGENCY ASSISTANCE of employment, lodging or other location from which You DURING YOUR TRIP CALL: PLAN FEATURES directly start Your Trip; TABLE OF CONTENTS 2. the scheduled Trip must not exceed 45 days length at the time of booking. 1-800-654-1908 Part I. Effective Date (From U.S.) Part II. Termination Date Part II. TERMINATION DATE Part III. General Exclusions Termination of Coverage for a Trip: All coverages with 1.804-281-5700 Part IV. Description of Travel Insurance Coverages respect to a given Trip end on the earliest of: Part V. General Provisions 1. Your arrival at Your residence, place of employment, (Collect) Part VI. Claims Filing Procedures lodging or other location at Your return destination to Part VII Definitions which You go directly following Your Trip; 2. Your return date: 3. cancellation of the Trip; Signed for BCS Insurance Company, 2 MidAmerica Plaza, 4. 12:01 A.M. on the 46th day after the date You started Global Assistance Suite 200, Oakbrook Terrace, IL 60181. Your Trip; or 5. at 12:01 A.M. on the 366th day after the Coverage Term starts. iA•actio4 Extension of Coverage for a Trip: All coverages will be extended with respect to a given Trip provided: 1. Your entire Trip falls within a Coverage Term; and 2. Your return is delayed by an event beyond Your control. If coverage is extended, coverage will end on the earlier of Your arrival at Your residence, place of employment, lodging BCS Insurance Company or other location at the return destination to which the insured Allianz Global Assistance and Allianz Travel Insurance branded directly goes following the Trip; or seven days after the return plans are underwritten by BCS Insurance Company. AGA Service 52.201.401.NY PC date. Company is the licensed producer for this plan. Page 1 ©2015 AGA Service Company TI_BCS_401_03_P_NY_V2S EFTA00317283 Termination of Annual Coverage: Premium is paid on an 10. Nuclear reaction, radiation or radioactive contamination; You have purchased a plan where Pre-existing Conditions are annual basis. Your insurance will continue in effect until 12:01 11. Natural disasters (unless as specifically covered); waived. We cover Pre-existing Conditions provided: A.M. on the 366th day after the date of the Coverage Term 12. Epidemic; 1. On the date of purchase of insurance. You were starts as shown on Your Letter of Confirmation. 13. Pollution or threat of pollutant release; or medically able to travel and You had not filed a claim for 14. Any commission of or attempt to commit a felony by You, Trip Cancellation due to a pre-existing Illness within 120 Part III. GENERAL EXCLUSIONS Family Members, or Traveling Companions, whether they days prior to the purchase of insurance; These exclusions apply to the following benefits: Trip are insured or not. 2. The total Trip cost is $10,000 per person or less; and Cancellation and Interruption Protection, Change Fee 3. On the date of purchase of insurance, You are a resident Coverage. Frequent Traveler/Loyalty Program Coverage, These plans do not cover You: of the United States. Travel Delay Coverage, Baggage Coverage, Baggage Delay 1. If the purpose of the travel is to receive medical care, Coverage. Business Equipment Coverage, and Business medication or treatment; If You do not meet the above criteria, You may still be covered Equipment Rental Coverage. 2. If You are not a resident of the USA; for Trip Cancellation or Trip Interruption caused by reasons 3. If the stated Trip departure and return dates do not reflect other than those related to a Pre-existing Condition. In addition to any exclusions that apply to a particular benefit, Your intended departure and return dates; no coverage is provided for any loss arising directly or 4. If the tickets and rental contract do not indicate the travel Part IV. DESCRIPTION OF TRAVEL INSURANCE indirectly out of or as a result of the following: dates; COVERAGES (what is covered) 1. Intentionally self-inflicted harm, suicide or attempted 5. If You give incorrect data or facts; or The following insurance benefits are designed to protect You suicide by You, Your Traveling Companion or Your 6. If the loss is not submitted to Us within 120 days from the against situations or losses that result from sudden and Family Member; date of loss, except as otherwise prohibited by law. unexpected conditions or events. The benefits do not cover 2. Normal Pregnancy (unless as specifically covered), foreseeable events on the date of insurance purchase. Please fertility treatments, Childbirth or elective abortion, other PRE-EXISTING CONDITIONS EXCLUSION AND WAIVER be aware that this stipulation may be applied to policies than unforeseen complications of pregnancy, of You, a This exclusion applies to Trip Cancellation and Interruption purchased with the Pre-existing Conditions Exclusion Waiver. Traveling Companion, or a Family Member; Coverage. and to those travel assistance services related to 3. Mental or nervous health disorders, including but not medical problems. TRIP CANCELLATION AND INTERRUPTION COVERAGE limited to: anxiety. depression, neurosis or psychosis; or Trip Cancellation Coverage provides benefits for loss(es) You physical complications resulting from the mental or The plan does not cover losses or expenses if they result from: incur for Trips canceled up to the time and date of departure. nervous health disorder related thereto of You, a 1. Any injury to You, a Traveling Companion, or a Family Trip Interruption Coverage provides benefits for loss(es) You Traveling Companion or a Family Member. Member occurring prior to the effective date of Your incur for Trips that are interrupted or delayed after the time 4. Alcohol or substance abuse or use (unless administered insurance; or and date of departure. on the advice of a Physician): or conditions or physical 2. Any illness occurring to You, a Traveling Companion, or a complications related thereto of You, a Traveling Family Member during the 120 days prior to the effective For all covered reasons outlined below, You must notify the Companion or a Family Member; date of Your insurance for which: (a) medical diagnosis or appropriate travel supplier(s) of Your cancellation or 5. War (whether declared or undeclared), acts of war, treatment by a Physician has been sought or advised or interruption within 72 hours of the occurrence, unless the military duty (unless as specifically covered), civil disorder for which symptoms exist which would cause a prudent condition prevents it then as soon as reasonably possible. or unrest (except as provided for in Travel Delay): person to seek diagnosis, care, or treatment or (b) require Otherwise the right to compensation will lapse. 6. Participation in professional or amateur sporting events taking prescribed drugs or medicine unless the illness (including training); remains controlled without any change in the required A maximum benefit of up to the amount indicated on Your 7. All extreme, high risk sports including but not limited to: prescription. Letter of Confirmation is provided to cover certain expenses as bodily contact sports; skydiving; hang gliding, bungee listed below which result from the cancellation of Your Trip due jumping, parachuting; mountain climbing or any other For the purposes of determining any Pre-existing Conditions, to: high altitude activities, caving, heli-skiing, extreme skiing, the effective date of Your insurance will be Your Trip 1. Any serious Injury or any unforeseen serious medical or any skiing outside marked trails; Cancellation Coverage effective date, if Trip Cancellation condition: 8. Scuba diving (unless accompanied by a dive master and Coverage is purchased. If no Trip Cancellation Coverage is a. Occurring to You or a Traveling Companion, which is not deeper than 130 feet); purchased. it will be Your Trip departure date. so disabling as to cause a reasonable person to 9. Operating or learning to operate any aircraft as pilot or delay, cancel, or interrupt their Trip; crew; Page 2 EFTA00317284 b. Occurring to a Family Member that is considered life For foreign Terrorism coverage only, coverage for travel 17. You or a Traveling Companion become legally separated threatening or requiring hospitalization; or to or through countries in which such a documented or or divorced after the purchase of insurance and prior to c. Occurring to a Family Member requiring Your care. reported incident has occurred during the 30 days prior to the departure date, provided that the Insurance was For Trip Cancellation benefits: an actual examination by a purchase of the insurance is excluded. Losses resulting purchased within 14 calendar days of the initial Trip Physician must take place within 72 hours of the due to the issuance of travel advisories, bulletin or alerts; deposit or payment. cancellation. For Trip Interruption benefits: this war or acts thereof; civil disorder, riot or unrest; bomb examination must take place during Your Trip. This scares or threats of terrorist activity; or Terrorist Ads Coverage is for: Physician may not be a member of Your or Your against any Common Carrier (e.g., airline or cruise line) 1. Forfeited, published, Trip payments or deposits incurred Traveling Companion's family or yourself, or a Family are not covered. as a result of cancellation penalties for which You are not Member of the person whose condition caused the 9. You or a Traveling Companion, who are on Active Military eligible to receive a Refund; cancellation or interruption. Duty in the United States Armed Forces: 2. For Trip Interruption, the pro-rated portion of the pre-paid 2. Your death, the death of a Family Member or a Traveling a. having Your personal leave revoked within 10 days Trip missed; Companion if the death occurs within 30 days prior to prior to Your departure date (as long as such 3. The additional cost resulting from a change in the per- Your Scheduled Departure Date or during Your Trip. revocation is in writing by a superior officer and is person occupancy rate for prepaid travel arrangements if 3. Strikes, natural disasters, severe weather or FM not due to war-related situations, invocation of the a Traveling Companion's Trip is canceled or interrupted mandated shutdown resulting in the complete cessation War Powers Act, base or unit mobilization, unit for one of the above covered reasons and Yours is not; of services by the airline, the tour operator or the cruise reassignment for any reason, or disciplinary action); 4. Reasonable, additional accommodation and line for at least 24 consecutive hours or a road closure or transportation expenses up to 5100 per day up to a causing a delay in reaching Your destination for at least b. are personally reassigned within 10 days prior to maximum of five days if a covered Traveling Family 12 consecutive hours. The Company will not cover losses Your departure date, whether temporary or Member or Traveling Companion must remain resulting from strikes of the person, organization, agency, permanent. hospitalized; or tour operator, or their affiliate companies, that solicited 10. You or a Traveling Companion being the victim of a 5. Reasonable, additional travel costs for You to reach Your this coverage andJor Your insured travel arrangements to Felonious Assault within 10 days prior to Your departure original destination if You must depart after Your planned You. date or during Your Trip. A Felonious Assault may not be departure date due to one of the above reasons; or 4. You or a Traveling Companion being hijacked, carjacked inlicted by You, a Family Member, Traveling Companion 6. Reasonable, additional transportation expenses needed or quarantined. or Traveling Companion's Family Member. to reach the scheduled termination point of Your Trip or to 5. You are required to serve on a jury, served with a court 11. You or Your Traveling Companion, after having been with travel from the place Your Trip was interrupted to the order or subpoena. the same employer for at least three continuous years, place where You can rejoin Your Trip and the unused 6. Your Primary Residence being made uninhabitable by are terminated or laid off, through no fault of Your own, portion of any non-refundable land, sea and air fire, flood, burglary, vandalism, or natural disasters. after Your effective date of coverage. arrangements that were paid as part of Your Trip. 7. You or a Traveling Companion being directly involved in a 12. Your family or friends living abroad with whom You were traffic Accident that causes either: a) a medical planning to stay, are unable to accommodate You due to The benefits paid under 5 and 6 above wil not exceed the cost emergency for You or a Traveling Companion; or b) life threatening Illness, life threatening Injury or death of of economy airfare by the most direct route on the next damage to the automobile, which creates an immediate one of them. available carrier, less any Refunds paid to You. need for repair to ensure the safety of the passengers. 13. A covered Travel Delay that results in the loss of more 8. Terrorist Acts committed by organized terrorist groups than 50% of Your scheduled Trip length. Trip Cancellation/Interruption benefits do not cover loss(es) (recognized as such by the U.S. State Department) that 14. Theft of Your automobile that results in Your inability to due to: result in property damage, Injury or loss of life. The take or continue Your Trip. 1. Any General Exclusion or Pre-existing Condition; incident must take place in a domestic or foreign city in 15. For Trip Cancellation only: Your Normal Pregnancy, as 2. You or a Traveling Companion: a) making changes to which You are scheduled to arrive within 30 days long as the pregnancy occurs after Your effective date of personal plans; b) having a business or contractual following the incident and Your tour operator (if coverage that can be verified by medical records. obligation; c) being unable to obtain necessary travel applicable) must not have offered a substitute itinerary. 16. For Trip Cancellation only: You will be attending a Family documents; or d) being detained or having property Member's Childbirth at the time the covered Trip is confiscated by any Customs authority; scheduled to take place as long as the pregnancy occurs 3. Carrier caused delays (including bad weather) unless as after the effective date of coverage that can be verified by covered above; medical records. Page 3 EFTA00317285 4. Prohibition or regulation by any government; or Covered reasons for Travel Delay are: 4. Bicycles, skis. snowboards (except when checked with a 5. Travel arrangements canceled by the airline, cruise line 1. Carrier caused delay (including bad weather); Common Carrier); or tour operator. 2. Lost or stolen passports, money, or travel documents; 5. Aircraft, boats or any other vehicles or conveyances; 3. Quarantine: 6. Eyeglasses, sunglasses, contact lenses, hearing aids, Please refer to Your Letter of Confirmation for the maximum 4. Hijacking: artificial teeth and limbs; coverage amount available under Your plan. 5. Unannounced strikes; 7. Tickets, keys, money, securities, bullion, stamps, credit 6. Natural disaster; cards, documents (travel or otherwise) and deeds; CHANGE FEE COVERAGE 7. Civil disorder or unrest; or 8. Property shipped as freight or shipped prior to Your Trip A maximum benefit of up to the amount indicated on Your 8. Severe storms that cause a route closing validated by the departure date: Letter of Confirmation is provided to cover for loss(es) You National Weather Service records and local Department 9. Rugs or carpets of any type; incur if You have to change the dates of Your airline ticket for of Transportation records. 10. Perishables, medicines, perfumes, cosmetics and the covered reasons stated below: consumables; 1. A medical emergency (requires an actual examination by No coverage will be provided for loss(es) due to any General 11. Property used in trade, business or for the production of a Physician) occurring to You. a Traveling Companion or Exclusion. income or offered for sale or trade or components of a Family Member; or goods offered for sale or trade; 2. You or a Traveling Companion being delayed by bad Please refer to Your Letter of Confirmation for the maximum 12. Property that is left in or on a car trailer; weather while en route to a departure provided the car coverage amount available under Your plan. 13. Property that is left in a vehicle if the vehicle is not was scheduled to arrive at the point of departure at least properly secured; or two hours before the scheduled time of departure. BAGGAGE COVERAGE 14. Damage to the property resulting from defective materials Coverage is secondary to any coverage provided by a or workmanship, ordinary wear and tear, and normal No coverage will be provided for loss(es) due to any General Common Carrier or hotel, if any. deterioration. Exclusion. If Baggage is lost, damaged or stolen, the Company will pay The plan will pay the lesser of: Please refer to Your Letter of Confirmation for the maximum the loss, up to the maximum amount indicated on Your Letter 1. The actual purchase price of a similar item; or coverage amount available under Your plan. of Confirmation, provided You have taken all reasonable 2. The Actual Cash Value of the item at the time of loss, measures to protect, save andlor recover Your property at all which includes deduction for depreciation (for items FREQUENT TRAVELEFULOYALTY PROGRAM COVERAGE times. Notwithstanding the foregoing, We will cover up to a without receipts, the plan will pay up to 75% of the If You used frequent traveler awards (frequent flyers miles or maximum amount of $500 for any and all jewelry, watches, determined depreciated value); or hotel rewards) for any part of a Trip, the Company will pay the gems, furs, cameras, and camera equipment, camcorders, 3. The cost to repair or replace the item. fees incurred by You for re-depositing those awards in Your sporting equipment, computers, radios and other electronic account if the Trip is canceled for any of the reasons under items and only when original receipts are provided. Please refer to Your Letter of Confirmation for the maximum Trip Cancellation and Interruption Coverage. coverage amount available under Your plan. You must notify the appropriate local authorities at the place Please refer to Your Letter of Confirmation for the maximum the loss occurred and inform them of the value and description BAGGAGE DELAY COVERAGE coverage amount available under Your plan. of Your property within 24 hours after the loss. Finally, You If Your personal Baggage is delayed or misdirected for at least must file written proof of loss with the Company within 120 24 hours by a Common Carrier, the plan will reimburse You on TRAVEL DELAY COVERAGE days from the date of loss, except as otherwise prohibited by a one-time basis for the reasonable, additional purchase of Coverage under the plan will pay on a one-time basis up to the law. attaching copies of airline, cruise line or Common Carrier essential items. Verification of the delay by the Common maximum amount listed on Your Letter of Confirmation for claim forms, original police reports, an itemization and Carrier and receipts for the emergency purchases must reasonable, additional accommodation and traveling expenses description of lost items and their estimated value, and all accompany any claim. due to a departure delay of six or more hours. Prepaid receipts. credit card statements, canceled checks. photos, or expenses are not covered. Expenses must be incurred by other appropriate documentation as may be required. No coverage will be provided for loss(es) due to any General You. Payments for additional expenses will not exceed $150 Exclusion. per day per person for all persons insured under Your Policy Property or losses not covered: as named on Your Letter of Confirmation. 1. Losses incurred as a result of any General Exclusion; Please refer to Your Letter of Confirmation for the maximum 2. Animals; coverage amount available under Your plan. 3. Automobiles and equipment, motorcycles and motors; Page 4 EFTA00317286 BUSINESS EQUIPMENT COVERAGE BUSINESS EQUIPMENT RENTAL COVERAGE misstatements, made by the insured shall be used to void Coverage is secondary to any coverage provided by the If Your business equipment is damaged. lost or delayed by the the Policy or to deny a claim for loss incurred or disability Common Carrier. Common Carrier for 12 hours or more, or stolen, the plan will (as defined in the Policy) commencing after the expiration reimburse You on a one-time basis for the reasonable costs of of such two year period. If Your business equipment is lost by the Common Carrier, or renting business equipment during Your Trip up to the amount 5. On the Policy effective date shown in the Letter of damaged, or stolen, We will pay up to the amount on Your indicated on Your Letter of Confirmation. Confirmation, if any provision conflicts with the laws of the Letter of Confirmation provided You have taken all reasonable State in which You reside, it shall be deemed amended to measures to protect, save and recover Your property at all A police report is required if Your business equipment is conform to law. times. stolen. A Common Carrier report is required for proof of 6. Appraisal: In case You and We shall tail to agree as to damage by, delay by or being lost by the Common Carrier. the Actual Cash Value or the amount of loss, then, on the Property or losses not covered: written demand of either, each shall select a competent 1. Losses incurred as a result of any General Exclusion; No coverage will be provided for loss(es) due to any General and disinterested appraiser and notify the other of the 2. Items other than business equipment Exclusion. appraiser selected within twenty days of such demand. 3. Intentional Acts; The appraisers shall first select a competent and 4. Gross negligence or willful and wanton conduct; Please refer to Your Letter of Confirmation for the maximum disinterested umpire; and failing for fifteen days to agree 5. Business equipment shipped as freight or shipped prior to coverage amount available under Your plan. upon such umpire, then upon Your or Our request, such Your Scheduled Departure Date; umpire shall be selected by a judge of a court of record in 6. Business equipment that is left in or on a vehicle or a car Part V. GENERAL PROVISIONS RELATED TO INSURANCE the state in which the property covered is located. The trailer: COVERAGES appraisers shall then appraise the loss, stating separately 7. Business equipment that is lost by a Common Carrier and 1. All suits, actions or legal proceedings arising from the Actual Cash Value and loss to each item: and, failing to the loss is not reported to the Common Carrier within 24 plans. benefits, or services provided through the plans agree, shall submit their differences, only, to the umpire. hours after the loss and a claim is not filed with the (collectively 'Controversies") may be submitted to binding An award in writing, so itemized, of any two when filed Common Carrier; desk arbitration in accordance with the rules then with Us shall determine the amount of Actual Cash Value 8. Business equipment that is stolen and the theft is not applying to the American Arbitration Association. Such and loss. Each appraiser shall be paid by the party reported to the appropriate authorities; or arbitration must be upon mutual agreement. No request selecting him and the expenses of appraisal and umpire 9. Damage to the business equipment resulting from for arbitration can be brought to recover benefits until 60 shall be paid by the parties equally. defective materials or workmanship, ordinary wear and days have elapsed following submission of Your entire tear and normal deterioration. claim to Us. No action in any form can be brought after Assignment: You may assign Your interest under the Policy three years from the date Your claim was submitted to by giving Us written notice of such assignment. The If Your business equipment is lost or stolen or damaged. the Us. assignment will not be effective until We receive the written plan will pay the lesser of: 2. No agent or other person has authority to accept or make notice. We do not assume any responsibility for the validity of 1. The cost to repair the item if damaged; or representations or information or alter, modify or waive any assignment. 2. An amount based on the age of the item as follows: any of the provisions of this Policy. Cancellation by Insured: The insured may cancel this Policy If up to 12 months old 90% of the purchase price 3. In the event that You are covered under another policy at any time by written notice delivered or mailed to the insurer, If up to 24 months old 50% of the purchase price issued by the Company that provides the same or similar effective upon receipt of such notice or on such later date as If up to 48 months old 25% of the purchase price coverage, the Company will refund any premium for the may be specified in such notice. In the event of cancellation or Over 48 months old 0% duplicate Policy that You choose. death of the insured, We will promptly retum the unearned 4. Misrepresentations and Fraud: Coverage shall be void if, portion of any premium paid. The earned premium shall be A police report is required for any stolen business equipment whether before or after a loss, the insured has concealed computed by the use of the short-rate table last filed with the claim. A Common Carrier report is required for any business or misrepresented any material fact or circumstance state official having supervision of insurance in the state where equipment claim due to the equipment being lost or damaged concerning this Policy or the subject thereof, or the the insured resided when the Policy was issued. Cancellation by a Common Carrier. In addition, damaged business interest of the insured therein, or if the insured commits will be without prejudice to any claim originating prior to the equipment may require inspection by Us prior to claims fraud or false swearing in connection with any of the effective date of the cancellation. payment and should be kept as proof of loss. foregoing. All statements made by the insured for the issuance of any Policy shall be deemed representations Please refer to Your Letter of Confirmation for the maximum and not warranties. After two years from the date of issue coverage amount available under Your plan. of this Policy no misstatements, except fraudulent Page 5 EFTA00317287 Physical Examinations and Autopsy: The Company has the Trip Cancellation, Trip Interruption, Change Fee and Covered Service means a service or supply specified herein right to physically examine You as often as reasonably needed Frequent Traveler/Loyalty Program Claims for which benefits will be provided. while a claim is pending. The Company may also require an 1. Any appropriate documentation that officially explains the Family Member means Your husband or wife; birth or autopsy in the case of death, where it is not forbidden by law. cause of Your Trip cancellation or interruption. My adoptive parent, child or sibling; stepparent; stepchild; The Company will bear all costs for these. explanation of diagnosis along with Your original itemized stepbrother, or stepsister; father-in-law, mother-in-law. son-in- Non•renewable: This Policy is issued for a single term and is bills, receipts, and proof of other insurance payments. law, daughter-in-law, brother-in-law, or sister-in-law; non-renewable. 2. Original unused tickets, copies of invoices, proof of grandparent or grandchild: and spouse of a grandparent or payments, and other documents that substantiate the grandchild. Part VI. CLAIM FILING PROCEDURES cost or occurrence of the Trip cancellation or interruption. Felonious Assault is an act of violence against You or a To obtain a claim form, visit Our website 3. Documentation of Refunds received from the travel Traveling Companion requiring medical treatment in a www.allianztravelinsurance.com or call 1.800.3347525 24 supplier(s) andlor Common Carrier(s). Hospital. hours a day. seven days a week. All benefits will be paid in 4. Copy of the supplier's literature that describes penalties. Hospital means a short-term, acute, general hospital, which: United States dollars. 5. A letter from the tour operator or an itemized bill from the 1. is primarily engaged in providing, by or under the travel agent stating the non-refundable amounts of the continuous supervision of Physicians, to inpatients, 1. Written notice of claim must be given within 120 days Trip costs. diagnostic services and therapeutic services for after a covered loss starts or as soon as reasonably Travel Delay Claims diagnosis. treatment and care of injured or sick persons; possible. Notice must include Your name and the Policy Original police. Common Carrier or other report that verifies 2. has organized departments of medicine and major Number. Failure to famish such proof within the time the cause and duration of the delay. surgery: required shall not invalidate nor reduce any claim if it was Baggage Claims 3. has a requirement that every patient must be under the not reasonably possible to give proof within such time, 1. Original claim determination from the Common Carrier, if care of a Physician or dentist; provided such proof is furnished as soon as reasonably applicable. 4. provides 24-hour nursing service by or under the possible and in no event, except in the absence of legal 2. Original police report or other report of local authorities. supervision of a registered professional nurse (R.N.); capacity. later than one year from the time proof is 3. Original receipts and list of stolen, lost or damaged items. 5. if located in New York State. has in effect a otherwise required. 4. Proof of loss providing amount of loss, date, time and hospitalization review plan applicable to all patients which 2. We, upon receipt of a notice of claim, will furnish to the cause of loss. meets at least the standards set forth in section 1861(k) insured such forms as are usually furnished by it for filing Baggage Delay Claims of United States Public Law 89-97 (42 USCA 13954k)); proofs of loss. If such forms are not fumished within 15 Proof from the Common Carrier that personal Baggage was 6. is duly licensed by the agency responsible for licensing days after the giving of such notice the claimant shall be delayed or misdirected for at least 24 hours. such Hospitals: and deemed to have complied with the requirements of this 7. is not, other than incidentally, a place of rest, a place Policy as to proof of loss upon submitting, within the time Part VII. DEFINITIONS primarily for the treatment of tuberculosis, a place for the fixed in the Policy for filing proofs of loss, written proof Accident means an unexpected, unintended, unforeseeable aged. a place for drug addicts, alcoholics, or a place for covering the occurrence, the character and extent of the event causing Injury. convalescent, custodial, educational or rehabilitative care. loss for which claim is made. Active Military Duty means serving in the United States Illness means a sickness, infirmity or disease that causes a 3. Payment will be made immediately upon receipt of due Armed Forces on a full-time basis, not including the United loss that begins during a Coverage Period and is not a Pre- written proof of loss. States Armed Forces Reserves. existing Condition. Actual Cash Value means the amount an item is determined Injury means bodily Injury caused by an Accident, directly and We will need certain information from You in the event You to be worth based on its market value, age and condition at independently of all other causes and sustained on or after the need to file a claim. This documentation will include, but is not the time of loss. effective date of this coverage and before the termination date. limited to, the following: Baggage means luggage and personal possessions, whether Benefits for Injury will not be paid for any loss caused by owned. borrowed or rented, taken by You on the Trip. sickness or other bodily diseases or infirmity. General Documentation Common Carrier means an entity licensed to carry Normal Pregnancy or Childbirth means a pregnancy or 1. Receipts and itemized bills for all expenses. passengers for hire on land, water or air, excluding vehide Childbirth that is free of complications or problems. 2. Original of any Refunds or expense allowances received rental companies. Physician means a licensed practitioner of the healing arts from Your tour operator, travel agency, Common Carrier Coverage Period means the time during which benefits are who is legally entitled to practice medicine in the applicable or other entity. payable hereunder, beginning on the effective date and ending field for which services are delivered. on the termination date. Page 6 EFTA00317288 Preexisting Conditions means: Trip means: INSURING CLAUSE 1. Any injury occurring to You, a Traveling Companion, or a 1. a period of round-trip travel to and from a destination that BCS Insurance Company, herein referred to as the Company, Family Member prior to the effective date of Your is at least 100 miles from Your main place of residence; will pay You the insurance benefits described in this Policy. insurance; or and Please refer to the accompanying Letter of Confirmation. It 2. Any illness occurring to You, a Traveling Companion, or a 2. such travel is not to obtain health care or treatment of any provides You with specific information about the plan You Family Member during the 120 days prior to the effective kind. purchased. Please contact Us immediately if You believe that date of Your insurance for which: a) medical diagnosis or We, Us or Our refers to BCS Insurance Company and its the Letter of Confirmation is incorrect. treatment by a Physician has been sought or advised or agents. for which symptoms exist which would cause a prudent You or Your refers to all persons listed on the Letter of person to seek diagnosis, care or treatment; or b) require Confirmation under the plan purchased. RENEWAL CONDITIONS taking prescribed drugs or medicine unless the illness This Policy is issued for a single term and is non-renewable. remains controlled without any change in the required prescription. Primary Residence means a person's fixed, permanent and PLEASE READ THIS POLICY CAREFULLY FOR FULL principal home for legal and tax purposes. DETAILS. Refund means: This Policy is a legal contract. The entire contract consists of 1. Money returned to You by the travel agent, tour operator, this Policy: any Endorsements or Riders attached to it: and the airline. cruise line or other travel supplier; Letter of Confirmation. Capitalized words are defined terms. 2. Any credit or voucher for future travel provided to You by Please see the Definitions section. the travel agent, tour operator, airline, cruise line or other travel supplier; or 3. Any credits, recoveries or reimbursements from Your PLAN FEATURES employer, another insurance company. a credit card TABLE OF CONTENTS issuer or any other institution. Scheduled Departure Date means the date You have Part I. Effective Date selected to begin travel as shown on Your Letter of Part II. Termination Date Confirmation and for which paid travel arrangements have Part III. General Exclusions been made. Part IV. Description of Travel Insurance Coverages Terrorism or Terrorist Act means the unsanctioned and Part V. General Provisions illegal use of force that caused destruction of property, Injury, Part VI. Claims Filing Procedures or death by an individual or group for the express or implied Part VII Definitions purpose of achieving a political, ethnic, or religious goal or result. Terrorism does not include general civil protest, unrest, rioting, or an act of war. Signed for BCS Insurance Company, 2 MidAmerica Plaza, Traveling Companion is a person traveling with You and who Suite 2O0. Oakbrook Terrace, IL 6O181. shares the same accommodations as You. Traveling Family Member is Your spouse, and any of Your unmarried children under age of 23. including step-children or legally adopted children, or grandparents and grandchildren liF -'7. "' " afirtaladf natant/ . when traveling together without a parent. Any unmarried child, PROIDENT regardless of age, who is incapable of self-sustaining employment by reason of mental Illness. developmental disability, mental retardation or physical handicap and became so incapable prior to age 23, shall be eligible for coverage. 52.201.401.NY PC 52.201.008.NY AN Page 7 EFTA00317289 Part I. EFFECTIVE DATE The plan does not cover losses or expenses if they result from: Coverage is not provided for Insurance coverage shall be effective at 12:01 A.M. on the 1. The existence of symptoms which would ordinarily cause 1. Expenses incurred as a result of any General Exclusion; date the scheduled Trip begins. In no event will coverage be a prudent person to seek diagnosis, care or treatment 2. Cosmetic surgery, except that cosmetic surgery shall not effective if all premiums due have not been received prior to within a 120 day period preceding the effective date of include reconstructive surgery when such service is the Scheduled Departure Date or prior to the date You cancel the coverage of the insured person; or incidental to or follows surgery resulting from trauma, Your Trip or it is canceled for any reason. 2. A condition for which medical advice or treatment was infection or other diseases of the involved part, and recommended by a Physician or received from a reconstructive surgery because of congenital disease or Part II. TERMINATION DATE Physician within a 120 day period preceding the effective anomaly of a covered dependent child which has resulted Coverage ends earliest of: a) at midnight on the date of return date of coverage of the insured person. in a functional defect; selected; b) upon return to Your city of residence; c) when the 3. Foot care, in connection with corns, calluses, flat feet, Trip is canceled; or d) the 45th day of the Trip. If return is For the purposes of determining any Pre-existing Conditions, fallen arches, weak feet, chronic foot strain or delayed for any covered reason, coverage is extended until the effective date of Your insurance will be Your Trip departure symptomatic complaints of the feet; You are able to return to Your city of residence. The day You date. 4. Dental care or treatment, except for such care or depart and the day You return are counted and included as treatment due to accidental injury to sound natural teeth separate days when determining duration of coverage. You have purchased a plan where Pre-existing Conditions are within 12 months of the accident and except for dental waived. We cover Pre-existing Conditions provided: care or treatment necessary due to congenital disease or Part III. GENERAL EXCLUSIONS 1. The insurance was purchased; and anomaly; These exclusions apply to the following benefits: Emergency 2. The total Trip cost is $10,000 per person or less. 5. Eyeglasses. hearing aids, and examination for the Medical and Dental Coverage, Emergency Medical prescription or fitting thereof; Transportation Coverage. Flight Insurance Coverage and Part IV. DESCRIPTION OF TRAVEL INSURANCE 6. Treatment given by a Family Member, whether or not a Travel Accident Coverage In addition to any exclusions that COVERAGES (what is covered) licensed provider; apply to a particular benefit, no coverage is provided for any The following insurance benefits are designed to protect You 7. Benefits provided under Medicare or other governmental loss arising directly or indirectly out of or as a result of the against situations or losses that result from sudden and program (except Medicaid), any state or Federal workers' following: unexpected conditions or events. The benefits do not cover compensation, employers' liability or occupational 1. Your intentionally self-inflicted injury, suicide or attempted foreseeable events on the date of insurance purchase. Please disease law; or suicide; be aware that this stipulation may be applied to policies 8. Treatment provided in a government hospital. 2. Your Normal Pregnancy; purchased with the Pre-existing Conditions Exclusion Waiver. 3. Your mental or emotional disorders, alcoholism or drug Please refer to Your Letter of Confirmation for the maximum addiction; EMERGENCY MEDICAL AND DENTAL COVERAGE coverage amount available under Your plan. 4. You being intoxicated or under the influence of any A maximum benefit of up to the amount listed on Your Letter of narcotic unless administered on the advice of a Confirmation is provided for covered Emergency Medical or EMERGENCY MEDICAL TRANSPORTATION COVERAGE Physician; Dental Coverage expenses incurred as a result of accidental Important 5. War or acts of war (whether declared or undeclared), Injury or Illness occurring during a Trip within the Coverage If Your emergency is immediate and life threatening, seek service in the Armed Forces or units auxiliary thereto Period. local emergency care at once. (unless as specifically covered), Your participation in a We will only pay Reasonable and Customary Charges for Your emergency medical transportation limit is the total riot or insurrection; or health care services or supplies provided by Physicians, amount available for all Covered Services described 6. Your commission of a felony, attempt to commit a felony licensed dentists, Hospitals, and Other Licensed Providers that below. Please refer to Your Letter of Confirmation to or to which a contributing cause was You being engaged are received during Your Trip which are Medically Necessary confirm that You have this benefit in Your plan and Your in an illegal occupation. for: total dollar limit. PRE-EXISTING CONDITIONS EXCLUSION AND WAIVER 1. Emergency Medical Care; and You or Your representative must contact Us and We must This exclusion applies to Emergency Medical and Dental 2. Emergency Dental Care. make all transportation arrangements in advance. We will not Coverage. Emergency Medical Transportation Coverage and pay for any of the services listed in this section if We didn't to those travel assistance services related to medical authorize and arrange it, unless any delay, during life problems. threatening or other emergencies that warrant emergency medical transportation for treatment, would cause further injury or death. Page 8 EFTA00317290 Moving You to a Hospital or medical clinic (emergency Transporting Your remains (repatriation of remains) TRAVEL ACCIDENT COVERAGE medical evacuation) We'll arrange and pay for the reasonable and necessary This benefit provides coverage for a loss due to a covered If You're seriously ill or injured during Your Trip and Our services to transport Your remains to one of the following: Accident. The loss must occur within 365 days of the covered medical team determines that the local medical facilities are • a funeral home near Your primary residence; or Accident. The plan will pay the full amount (as listed on Your unable to provide appropriate medical treatment: • a funeral home located in the United States. Letter of Confirmation), in a lump sum, for loss of life or any • Our medical team will consult with the local doctor; We'll also assist the sending and receiving funeral homes combination of two eyes, hands or feet: and one half of the • We'll identify the closest appropriate facility, make coordinate with each other. amount for loss of one eye. hand or foot. Loss of eye means arrangements and pay to transport You to that facility; and This benefit does not include funeral, burial or cremation total and irrecoverable loss of entire sight; and loss of hand or • Well arrange and pay for a Medical Escort if We determine expenses or related containment expenses for items such as a foot means the actual complete and permanent severance at one is necessary. coffin, urn or vault. or above the wrist or ankle joint. Death or loss must be a direct Getting You home after Your care (medical repatriation) Your representative must contact Us in advance to make result of the Accident sustained during the Coverage Period. If You're seriously ill or injured during Your Trip, under the care these arrangements. If this is not possible. Your representative of a local doctor and unable to continue Your Trip, medical must contact Us within a reasonable time, but no later than Benefits will be payable for only one loss, that being the repatriation takes place once Our medical team determines one year after the transportation. greatest amount. Benefits are payable to You or, if applicable, that You are medically stable to return home via commercial to Your estate unless You have named a beneficiary. transportation carrier, such as a scheduled passenger airline. FLIGHT INSURANCE COVERAGE We'll: Coverage is effective for the flights for which this plan was No coverage will be provided for loss due to any General • arrange and pay (less any refunds for unused tickets) for purchased. Coverage applies while You are riding, boarding or Exclusion, or for any loss due to air travel except while You You to be transported via a commercial transportation alighting as a fare-paying passenger on a flight provided by a are riding, boarding or alighting as a fare-paying passenger on carrier in the same class of service that You were booked scheduled airline on any scheduled Trip or charter. a scheduled or charter flight operated by a scheduled airline. for Your Trip. The transportation will be to one of the following: The loss must occur within 365 days of the covered Accident. Please refer to Your Letter of Confirmation for the maximum • Your primary residence: The plan will pay the full amount (as listed on Your Letter of coverage amount available under Your plan. • a location of Your choice in the United States: or Confirmation), in a lump sum, for loss of life or any combination of two eyes. hands or feet: and one-half of the NEW YORK MANDATES: Under New York Law, certain • a medical facility near Your primary residence or city of Your choice in the United States. We'll take Your amount for loss of one eye. hand or foot. Loss of eye means mandated benefits are required to be provided under a request into consideration as long as the medical total and irrecoverable loss of entire sight; and loss of hand or medical expense policy. We will pay benefits as applicable to foot means the actual complete and permanent severance at this program for such mandates. facility will accept You as a patient and is approved as medically appropriate for Your continued care by Our or above the wrist or ankle joint. Death or loss must be a direct medical director. result of the Accident sustained during the Coverage Period. Part V. GENERAL PROVISIONS RELATED TO INSURANCE COVERAGES • arrange and pay for a Medical Escort if Our medical team Benefits will be payable for only one loss, that being the 1. All suits, actions or legal proceedings arising from the determines a Medical Escort is necessary. greatest amount. Benefits are payable to You or, if applicable, plans. benefits, or services provided through the plans Bringing a friend or Family Member to You (transport to to Your estate unless You have named a beneficiary. (collectively "Controversies") may be submitted to binding bedside) desk arbitration in accordance with the rules then If You're told You will be hospitalized for more than seven This coverage does not include loss caused by or resulting applying to the American Arbitration Association. Such days during Your Trip, We'll transport a friend or Family from any of the following: arbitration must be upon mutual agreement. No request Member to stay with You. We'll arrange and pay for round-trip 1. Any General Exclusion; for arbitration can be brought to recover benefits until 60 transportation in economy class on a common carrier. 2. Disease or Illness; or days have elapsed following submission of Your entire Getting Your children home (return of dependents) 3. Travel on any device for aerial navigation except as claim to Us. No action in any form can be brought after If You're told You will be hospitalized for more than seven specially provided for in this coverage. three years from the date Your claim was submitted to days during Your Trip, Well arrange for and pay (less any Us. refunds for unused tickets) to transport Your children under the Please refer to Your Letter of Confirmation for the maximum 2. No agent or other person has authority to accept or make age of 23 who are traveling with You to one of the following: coverage amount available under Your plan. representations or information or alter, modify or waive • Your primary residence: or any of the provisions of this Policy. • a location of Your choice in the United States. 3. In the event that You are covered under another policy Transportation will be on a common carrier in the same class issued by the Company that provides the same or similar of service they were originally booked. Page 9 EFTA00317291 coverage, the Company will refund any premium for the hours a day. seven days a week. All benefits will be paid in Emergency Medical and Dental Claims duplicate Policy that You choose. United States dollars. Any explanation of diagnosis(es) along with Your original 4. Misrepresentations and Fraud: Coverage shall be void if, itemized bills and receipts. whether before or after a loss, the insured has concealed 1. Written notice of claim must be given to the insurer within Flight Insurance Claims or misrepresented any material fact or circumstance twenty days after the occurrence or commencement of Copy of death certificate. concerning this Policy or the subject thereof, or the any loss covered by the Policy, or as soon thereafter as is Travel Accident Claims interest of the insured therein, or if the insured commits reasonably possible. Notice given by or on behalf of the 1. Copy of death certificate. fraud or false swearing in connection with any of the insured or the beneficiary to the insurer at 2. Any explanation of diagnosis(es) along with Your original foregoing. All statements made by the insured for the www.allianztravelinsurance.com, by calling 1.800.334- itemized bills and receipts. issuance of any Policy shall be deemed representations 7525. or to any authorized agent of the insurer or to any and not warranties. After two years from the date of issue authorized broker, with information sufficient to identify Part VII. DEFINITIONS of this Policy no misstatements, except fraudulent the insured, shall be deemed notice to the insurer. Accident means an unexpected, unintended, unforeseeable misstatements, made by the insured shall be used to void 2. We, upon receipt of a notice of claim, will furnish to the event causing Injury. the Policy or to deny a claim for loss incurred or disability insured such forms as are usually furnished by it for filing Complications of Pregnancy means conditions requiring (as defined in the Policy) commencing after the expiration proofs of loss. If such forms are not furnished within 15 hospital stays (when the pregnancy is not terminated) whose of such two year period. days after the giving of such notice the claimant shall be diagnoses are distinct from pregnancy but are adversely 5. On the Policy effective date shown in the Letter of deemed to have complied with the requirements of this affected by pregnancy or are caused by pregnancy, such as Confirmation, if any provision conflicts with the laws of the Policy as to proof of loss upon submitting, within the time acute nephritis, nephrosis, cardiac decompensation, missed State in which You reside, it shall be deemed amended to fixed in the Policy for filing proofs of loss, written proof abortion and similar medical and surgical conditions of conform to law. covering the occurrence, the character and extent of the comparable severity, and shall not include false labor, loss for which claim is made. occasional spotting, physician-prescribed rest during the Assignment: You may assign Your interest under the Policy 3. Payment will be made immediately upon receipt of due period of pregnancy. morning sickness. hyperemesis by giving Us written notice of such assignment. The written proof of loss. gravidarum, preeclampsia and similar conditions associated assignment will not be effective until We receive the written 4. Written proof of loss must be furnished to the insurer at with the management of a difficult pregnancy not constituting a notice. We do not assume any responsibility for the validity of its said office in case of claim for loss for which this Policy nosologically distinct complication of pregnancy; and any assignment. provides any periodic payment contingent upon nonelective caesarean section, ectopic pregnancy which is Cancellation by Insured: The insured may cancel this Policy continuing loss within ninety days after the termination of terminated and spontaneous termination of pregnancy, which at any time by written notice delivered or mailed to the insurer, the period for which the insurer is liable and in case of occurs during a period of gestation in which a viable birth is effective upon receipt of such notice or on such later date as claim for any other loss within one hundred twenty days not possible. may be specified in such notice. In the event of cancellation or after the date of such loss. Failure to furnish such proof Coverage Period means the time during which benefits are death of the insured, We will promptly retum the unearned within the time required shall not invalidate nor reduce payable hereunder. beginning on the effective date and ending portion of any premium paid. The earned premium shall be any claim if it was not reasonably possible to give proof on the termination date. computed by the use of the short-rate table last filed with the within such time, provided such proof is furnished as Covered Service means a service or supply specified herein state official having supervision of insurance in the state where soon as reasonably possible and in no event, except in for which benefits will be provided. the insured resided when the Policy was issued. Cancellation the absence of legal capacity, later than one year from Emergency Dental Care means the services or supplies will be without prejudice to any claim originating prior to the the time proof is otherwise required. provided by a licensed dentist, Hospital or Other Licensed effective date of the cancellation. Provider that are medically and immediately necessary to treat Physical Examinations and Autopsy: The Company has the We will need certain information from You in the event You dental problems resulting from Injury, infection, breakage to right to physically examine You as often as reasonably needed need to file a claim. This documentation will include. but is not tooth surface or loss of filling. while a claim is pending. The Company may also require an limited to, the following: Emergency Medical Care means the services or supplies autopsy in the case of death, where it is not forbidden by law. provided by a Physician. Hospital or Other Licensed Provider The Company will bear all costs for these. General Documentation that are Medically Necessary to treat any covered medical 1. Receipts and itemized bills for all expenses. Illness or Injury that is acute (onset is sudden and unexpected) Part VI. CLAIM FILING PROCEDURES 2. Original of any refunds or expense allowances received and: To obtain a claim form, visit Our website from Your tour operator, travel agency, common carrier or 1. placing the health of the person afflicted with such www.allianztravelinsurance.com or call 1.800.3347525 24 other entity. condition in serious jeopardy, or in the case of a Page 10 EFTA00317292 behavioral condition placing the health of such person or trained to provide medical care to the person being Confirmation and for which paid travel arrangements have others in serious jeopardy; transported. A friend or Family Member cannot be a Medical been made. 2. serious impairment to such person's bodily functions; Escort. Traveling Companion is a person traveling with You and who 3. serious dysfunction of any bodily organ or part of such Medically Necessary means the services or supplies shares the same accommodations as You. person: provided by a Hospital, Physician or Other Licensed Provider Trip means a period of round-trip travel to and from a 4. or serious disfigurement of such person. that are required to identify or treat Your Illness or Injury and destination that is at least 100 miles from Your main place of Family Member means Your husband or wife; birth or which, as determined by Us. are: residence. adoptive parent, child or sibling; stepparent; stepchild; 1. consistent with the symptoms or diagnosis and treatment We, Us or Our refers to BCS Insurance Company and its stepbrother, or stepsister; father-in-law, mother-in-law, son-in- of Your condition. disease. Illness, ailment or Injury; agents. law, daughter-in-law, brother-in-law, or sister-in-law; 2. appropriate with regard to standards of good medical You or Your refers to all persons listed on the Letter of grandparent or grandchild; and spouse of a grandparent or practice; Confirmation under the plan purchased. grandchild. 3. not solely for the convenience of You. a Physician or Hospital means a short-term. acute, general Hospital, which: other provider; and 1. is primarily engaged in providing, by or under the 4. the most appropriate supply or level of service that can continuous supervision of Physicians, to Inpatients, be safety provided to You. diagnostic services and therapeutic services for When applied to the care of an Inpatient. it further means that diagnosis. treatment and care of injured or sick persons; Your medical symptoms or condition requires that the services 2. has organized departments of medicine and major cannot be safely provided to You as an Outpatient. surgery: Normal Pregnancy or Childbirth means free of any 3. has a requirement that every patient must be under the Complications of Pregnancy. care of a Physician or dentist; Other Licensed Providers means any person or entity other 4. provides 24-hour nursing service by or under the than a Hospital or Physician which is licensed. where required, supervision of a registered professional nurse (R.N.); to render medical or dental services. 5. if located in New York State. has in effect a Outpatient means a person who receives medical or dental hospitalization review plan applicable to all patients which services or supplies while not an Inpatient. meets at least the standards set forth in section 1861(k) Physician means a licensed practitioner of the healing arts of United States Public Law 89-97 (42 USCA 13954k)); who is legally entitled to practice medicine in the applicable 6. is duly licensed by the agency responsible for licensing field for which services are delivered. such Hospitals; and Pre-existing Conditions means: 7. is not, other than incidentally, a place of rest, a place 1. The existence of symptoms which would ordinarily cause primarily for the treatment of tuberculosis, a place for the a prudent person to seek diagnosis, care or treatment aged. a place for drug addicts, alcoholics. or a place for within a 120 day period preceding the effective date of convalescent, custodial, educational or rehabilitative care. the coverage of the insured person; or Illness means a sickness, infirmity or disease that causes a 2. A condition for which medical advice or treatment was loss that begins during a Coverage Period and is not a Pre- recommended by a Physician or received from a existing Condition. Physician within a 120 day period preceding the effective Injury means bodily Injury caused by an Accident, directly and date of coverage of the insured person. independently of all other causes and sustained on or after the Reasonable and Customary Charge means the amount effective date of this coverage and before the termination date. charged for a specific service in a particular geographic area Benefits for Injury will not be paid for any loss caused by as determined by contacting comparable medical sickness or other bodily diseases or infirmity. professional(s) in the same geographic area for the usual Inpatient means a person who is treated as a registered bed charge of similar services. Your health care provider may patient in a Hospital or Other Licensed Provider and for whom charge more than the established Reasonable and Customary a room and board charge is made. costs and these additional charges may not be covered by the Medical Escort means a professional person contracted by Policy. Our medical team to accompany a seriously ill or injured Scheduled Departure Date means the date You have person while they are being transported. A Medical Escort is selected to begin travel as shown on Your Letter of 52.201.008.NY All Page 11 EFTA00317293 TRAVEL ASSISTANCE SERVICES PROVIDED BY AGA Definitions Legal Assistance SERVICE COMPANY Hospital means a provider that is a short-term, acute, general If you have legal problems, our hotline center staff will help Our goal is to provide immediate help for common travel Hospital that: you find a local legal advisor. If you require the posting of bail problems almost everywhere in the world. However, despite 1. is a duly licensed institution; or immediate payment of legal fees. we will help arrange a our best efforts, situations arise which are beyond our control 2. in return for compensation from its patients, is primarily cash transfer from your family or friends. and under these circumstances, we can only promise to make engaged in providing inpatient diagnostic and therapeutic Emergency Cash Transfer every reasonable effort to help you resolve your problems. The services for the diagnosis. treatment, and care of injured If your cash or traveler's checks are lost or stolen, or if you hotline center staff will do its best to refer you to appropriate and sick persons by or under supervision of physicians; need kinds for the immediate payment of unanticipated medical and legal providers. However, we cannot be held 3. has organized departments of medicine and major expenses, we will help arrange to have emergency cash (in responsible for the quality of results of any medical or legal surgery: currency. traveler's checks or any other form acceptable to us) services provided by these independent practitioners. 4. provides 24-hour nursing service by or under the transmitted to you from your family or friends. Our hotline If you are in trouble and need help: supervision of registered graduate nurses; and center staff will make all the necessary arrangements for you. 1. Call the hotline. From the U.S. call 14004541908. 5. is not other than incidentally: a) a skilled nursing facility, Emergency Message Center From all other locations call collect to 1.804281.5700. nursing home, custodial care home, health resort, spa or In the event of an emergency, call the hotline center, identify If your emergency is immediate and life threatening, seek local sanatorium, place for rest, place for the aged. place for the yourself by your ID number, and give the hotline coordinator emergency assistance at once and contact the hotline as soon provision of rehabilitation care; b) a place for the treatment your message. We will make at least 3 attempts in 24 hours to as possible. of mental illness; c) a place for the treatment of alcoholism reach your requested party, and we will provide you with an 2. Have the following information ready for the hotline or drug abuse; d) a place for the provision of hospice care; update on the disposition of our attempts to deliver the coordinator: ore) a place for the treatment of pulmonary tuberculosis. message. (We are not responsible for delivery of a message if a. Your name and ID number; and Medically Necessary means the services or supplies the recipient cannot be reached). This service can be used for b. Your location and local telephone number. provided by a Hospital, physician or other licensed provider trips anywhere in the world. The hotline coordinator will confirm your enrollment and that are required to identify or treat your illness or injury and Flight Information provide you with assistance. which, as determined by us, are: If you are faced with a canceled or missed flight, just call the Note: In some countries it may not be possible to call collect. If 1. consistent with the symptom or diagnosis and treatment of hotline center for 24-hour information on alternate flights. We you must phone the hotline directly, give your location and your condition, disease, illness, ailment or injury; can provide you with scheduled departure and arrival times of phone number to the hotline coordinator who will call you 2. appropriate with regard to standards of good medical alternate, direct flights only. We do not book reservations or back. practice; pay for tickets. This service can be used on trips within the 3. not solely for the convenience of you, a physician or other U.S.. Canada, the Caribbean and Mexico only. Medical Assistance provider; and If you have medical problems and are unable to find local care, 4. the most appropriate supply or level of service that can be CONCIERGE SERVICES we will refer you to a local physician, dentist, Hospital, medical safely provided to you. While on your covered trip, we can help make your vacation facility or other appropriate resource, when available. When applied to the care of an inpatient, it further means that more memorable. Please contact us for: Medical Consultation and Monitoring your medical symptoms or condition requires that the services • Restaurant and local event information If you are hospitalized, the hotline center medical staff will cannot be safely provided to you as an outpatient. • Emergency and after hours hotel information and keep in frequent contact with you and your local physician to reservations get information on the care you are receiving and to determine Travel Document and Ticket Replacement Assistance • Golf tee times, information, referrals and reservations the need for further assistance. We will also contact your The plan provides you with information to assist in obtaining All of our concierge benefits are service benefits, not personal physician and family at home, if necessary. replacements of lost passports or other important travel financial benefits. Any costs associated with the services On-Site Hospital Payments documents. We also help you to replace lost airline and other are paid by you. We will advance payments to Hospitals or guarantee travel tickets and will assist you in obtaining money for this payments to secure your Medically Necessary admission to a purpose. These funds will come from your family or friends. Hospital. You must have the Emergency Medical & Dental We will make all the necessary arrangements for you, Benefits and the maximum guarantee will be up to the limits including assisting you to return home if your trip is interrupted. specific in the Letter of Confirmation. TI_BCS_401_03_P_NY_V2S Page 12 EFTA00317294 This page intentionally left blank This page intentionally left blank We're only a CLICK away! Visit www.allianztravelinsurance.com to: • File a claim • Check claim status Global Assistance Page 13 TI_BCS2101_03_P_NY_V2S 05/15 EFTA00317295 BCS INSURANCE COMPANY (A Stock Company) ENDORSEMENT Required to Work Coverage The Policy to which this endorsement is attached is amended to include the following I. Part V. DESCRIPTION OF TRAVEL INSURANCE BENEFITS (what is covered), the following Covered reasons are added to the Trip cancellation and Trip Interruption coverage. 1. You or a Traveling Companion are required to work during Your scheduled Trip. You must demonstrate proof of requirement to work, such as a notarized statement signed by an officer of Your employer. 2. Your company being made unsuitable for business by fire, flood, burglary, vandalism or natural disasters. 3. Your company being directly involved in a merger or acquisition. You must be an active employee of the company that is merging and You must be involved in such an event. II. The following limitation provision is deleted in its entirety: Trip Cancellation/Interruption benefits do not cover loss(es) due to: 1. Any General Program Exclusion or Pre-Existing Condition; 2. You or a Traveling Companion: a) making changes to personal plans: b) having a contractual obligation; c) being unable to obtain necessary travel documents; or d) being detained or having property confiscated by any Customs authority; 3. Carrier caused delays (including bad weather) unless as covered above; 4. Prohibition or regulation by any government (unless as specifically covered above); or 5. Travel arrangements cancelled by an airline, cruise line, or tour operator. and replaced with the following: Trip Cancellation/Interruption benefits do not cover loss(es) due to: 1. Any General Program Exclusion or Pre-Existing Condition: 2. You or a Traveling Companion: a) making changes to personal plans: b) being unable to obtain necessary travel documents; or c) being detained or having property confiscated by any Customs authority; 3. Carrier caused delays (including bad weather) unless as covered above; 4. Prohibition or regulation by any government (unless as specifically covered above): or 5. Travel arrangements cancelled by an airline, cruise line, or tour operator. There are no other changes to the Policy. BCS Insurance Company )1,thvbvi PRE310(14T 52.201.OE.01 EFTA00317296 BCS Insurance Company Privacy Notice BCS respects the privacy of its customers and farmer customers and protects the security and confidentiality of their nonpublic personal information. To safeguard our customers' confidential information, we comply with all applicable laws and regulations and have instituted our own policies to: (1) insure the security and confidentiality of customer records and information; (2) protect against any anticipated threats or hazards to the security or integrity of such records: and (3) protect against unauthorized access to or use of such records or information which could result in substantial harm or inconvenience to any customer. BCS PRIVACY POLICY: Policies and practices with respect to disclosing your nonpublic personal information: We do not disclose any nonpublic personal financial information about our customers or former customers to anyone, except as permitted by law. Categories of nonpublic personal information that we collect: We collect nonpublic personal financial information about you from the following sources: (1) information we receive from you on applications or other forms; (2) information about your transactions with us, our affiliates, or others, and; (3) information we receive from a consumer reporting agency. Policies we maintain to protect the confidentiality and security of nonpublic personal information: We maintain physical, electronic, and procedural safeguards that comply with federal and state regulations to guard your nonpublic personal financial information. We restrict access to your nonpublic personal information to employees who need it to provide information or services to you. AGA Service Company d/bla Allianz Global Assistance is the administrator of this insurance policy on behalf of BCS Insurance Company. We will adhere to at least the same standards for handling and protecting your data as described above. For more information about how we handle and protect your data, please see our privacy policy, located at http://mws.alfianzassistance.com/privacy or contact us at: Allianz Global Assistance, ATTN: Chief Privacy Officer. P. O. Box 72031. Richmond, VA 23255-2031. BCSPRIVNOT EFTA00317297