Summary of Benefits1 Lifetime Medical Maximum $500,000 Deductible $0 Co insurance Rate The Company Pays 100% of the UCC Prescription Drugs Surgical Treatment $1,000 Covered to the maximum benefit Mental & Nervous Disorders Treated as any other medical condition Pregnancy Covered as any other medical condition; conception must occur while policy is in force Sports Related Injury $3,000 Accidental Death & Dismemberment Emergency Medical Evacuation $500,000 Repatriation of Mortal Remains $500,000 Comprehensive Security Evacuation $250,000 Pre existing Condition Limitation 3 Month for prescription drugs only Trip Interruption $2,000 24/7 Assistance Services Assist America This chart serves as a summary only. For a full description of the coverages provided please refer to the master policy kept on file with Hart Travel Partners How to File a Claim Print and fill out the below claim form. Be sure to complete every question and attach itemized bills Send via email to aciclaims@visit aci.com, or via fax 1.610.293.9299 You may also mail your claim documents to Administrative Concepts 994 Old Eagle School Road Suite 1005 Wayne, PA 19087 Be sure to send in your claim within 90 days of the treatment as this is the designated incurral period As you are traveling overseas, there may be cases where you will need to pay for the medical services up front and submit your claim form for reimbursement. Be sure to keep all of your receipts and any other documents provided to you by the facility. In non emergency situations, you should call Assist America first for referrals to English speaking facilities in your area. In emergency situations, you or someone who can represent you should call the assistance carrier as soon as possible. Contact information will be listed on your ID Card. We also recommend saving the number in your cell phone (if applicable) under emergency contact, medical services. Assist America provides a free application for insured’s. If applicable you should download the application prior to departure. For more information, and to download the app, please visit http://itunes.apple.com/us/app/assist america mobile/id463805175?mt=8 In order to check the status of your claim, you may call Administrative Concepts at 1 888 293 9229, or email aciclaims@visit aci.com. For assistance with claims you can also email [email protected] or contact 1 212 693 3717. Online claim status is available through https://secure.visit aci.com/insuredlogin.asp. It is recommended that you create an account prior to departure. The information needed to enroll will be provided to you on your ID card. MAIL TO: Administrative Concepts, Inc. 994 Old Eagle School Road Suite 1005 Wayne, PA 19087-1802 www.visit-aci.com Any person who knowingly Policyholder Name of Insured Individual: Home Address: Insurance Company CLAIM FORM COMPLETE IN DETAIL TO ENSURE PROMPT HANDLING knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Group Plan or Program: Present Address: A Last Name Policy Number Certificate/I.D. Number First Name Middle Initial No. and Street City or Town State Zip Code Country No. and Street City or Town State Zip Code Country Telephone Number: Date of Birth: If payment is to be made to someone other than the Insured, who is to receive payment? Relationship to insured: Address: Date of Accident or Sickness: Nature of Accident or Sickness: Male Female (Circle One) If accident, describe fully how and where accident occurred: If injured in play or practice of sport, indicate what sport: Is the insured covered under any other group plan, health maintenance organization, government plan, or insurance policy? Yes ❏ No ❏ Insurance Company: Are you covered as a dependent under this policy? Yes ❏ Policy Number: No ❏ INSURED OR PARENT MUST SIGN BELOW: IF PAYMENT IS TO BE ASSIGNED TO PROVIDER, SIGN Insured’s Signature: Insured’s Signature: Date: Date: Authorization: I hereby authorize release to BELOW: Administrative Concepts, Inc., any and all Authorization: I hereby authorize payment of medical information concerning advice, care or treatment benefits to the medical provider identified on this form, for provided to myself or any of my family which may the service described. be needed to process this claim. Administrative Concepts, Inc. does not share private health information except as required or permitted by law. We are committed to guarding the private information entrusted to us. Physician or Provider Information (Please Attach Universal 1500 Form or Fill Out In Full Below) Date of First Symptom of Illness Date First Consulted you for Has Patient Ever Had Same or or Injury: this condition: Similar Symptoms? Yes ❏ No ❏ Diagnosis: History of Illness or Injury: Name of Referring Physician or Other Source: For Services Related to Hospitalization (Give Date) Admitted: Discharged: Name and Address of Facility Where Services Rendered: Was Laboratory Work Performed Outside Your Office? Yes ❏ No ❏ Lab Charges: Date of Service Place of Service CPT Code Provider’s Signature Date Print Provider’s Name Provider’s Address CMI- Description of Service Will You Accept Assignment?: Yes ❏ No ❏ ICD-9 Total Charges: Tel. # Fax # Tax I.D. # Charge PART II Please Print All Information Have you been covered (as an insured or dependent) by any other hospital and/or medical plan for the past 12 months? Yes No If yes, indicate the name and address of the company Effective date of coverage: Have you filed a claim with any other insurance company? Expiration date: Yes Policy No. No I hereby certify that the above information given by me in support of this claim is true and correct. Patient’s or Authorized Representative’s Signature Date If Authorized Representative, Relationship to Patient or Legal Designation The following section is applicable if you are covered under any other medical insurance plan. Mother’s Name Employer’s Telephone # Policy No. Employer’s Telephone # Policy No. Employer’s Telephone # Policy No. Employer’s Name and Address Name and Address of Insurance Co. Father’s Name Employer’s Name and Address Name and Address of Insurance Co. Spouse’s Name Employer’s Name and Address Name and Address of Insurance Co. The laws of some states require us to furnish you with the following noces: WARNING. Any person who knowingly: Alaska: and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading informaon may be prosecuted under state law. Arizona Arkansas : presents a false or fraudulent claim for payment of a loss or benefit is subject to criminal and civil penales, or specific to AR : presents false informaon in an applicaon for insurance is guilty of a crime and may be subject to fines and confinement in prison. California: For your protecon California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Delaware: and with intent to injure, defraud or deceive an insurer, files a statement of claim containing any false, incomplete or misleading informaon is guilty of a felony. District of Columbia: It is a crime to provide false or misleading informaon to an insurer for the purpose of defrauding the insurer or any other person. Penales include imprisonment and/or fines. In addion, an insurer may deny insurance benefits if false informaon materially related to a claim was provided by the applicant. Florida: and with intent to injure, defraud, or deceive any insurer, files a statement of claim or applicaon containing any false, incomplete, or misleading informaon is guilty of a felony of the third degree. Idaho and Indiana: and with intent to defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading informaon (for Idaho) is guilty of and (for Indiana) commits a felony. Kentucky, New York and Pennsylvania: and with intent to defraud any insurance company or other person files an applicaon for insurance, or files a statement of claim, containing any materially false informaon or conceals, for the purpose of misleading, informaon concerning any material fact thereto commits a fraudulent insurance act, which is a crime, specific to PA: subjects such person to criminal and civil penales and specific to NY: shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violaon. Louisiana, New Mexico, Texas and West Virginia: presents a false or fraudulent claim for the payment of a loss (or specific to LA, TX and W VA: who knowingly presents false informaon on an applicaon for insurance) is guilty of a crime and may be subject to fines and confinement in state prison, (or specific to NM: to civil fines and criminal penales.) Maryland: and willfully presents a false or fraudulent claim for payment of loss or benefit or who knowingly and willfully presents false informaon in an applicaon for insurance is guilty of a crime and may be subject to fines and confinement in prison. New Jersey: files a statement of claim containing any false or misleading informaon is subject to criminal and civil penales. Ohio: with intent to defraud or knowing that he is facilitang a fraud against an insurer, submits an applicaon or files a claim containing a false or decepve statement is guilty of insurance fraud. Oklahoma: and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading informaon is guilty of a felony. Oregon: and with intent to defraud any insurance company or other person files an applicaon for insurance or a statement of claim containing any materially false informaon or conceals for the purpose of misleading, informaon concerning any fact material hereto, may be subject to prosecuon for insurance fraud. Puerto Rico: and with the intenon of defrauding presents false informaon in an insurance applicaon, or presents, helps, or causes the presentaon of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon convicon, shall be sanconed for each violaon with the penalty of a fine of not less than five thousand (5,000) dollars and not more than ten thousand (10,000) dollars, or a fixed term of imprisonment for three (3) years, or both penales. If aggravang circumstances are present, the penalty thus established may be increased to a maximum of five (5) years; if extenuang circumstances are present, it may be reduced to a minimum of two (2) years. WARNING: Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or informaon to an insurance company for the purpose of defrauding or aempng to defraud the company. Penales may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or informaon to a policyholder or claimant for the purpose of defrauding or aempng to defraud the policyholder or claimant with regard to a selement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. Hawaii: Presenng a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. Maine/Washington: It is a crime to knowingly provide false, incomplete or misleading informaon to an insurance company for the purpose of defrauding the company. Penales may include imprisonment, fines or a denial of insurance benefits. Minnesota: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading informaon is subject to prosecuon and punishment for insurance fraud, as provided in RSA 638.20. Tennessee and Virginia : It is a crime to knowingly provide false, incomplete or misleading informaon to an insurer or insurance company for the purpose of defrauding the insurer or insurance company. Penales include imprisonment, fines and denial of insurance benefits. Frequently Asked Questions If I have a medical emergency, should I call the assistance center number, before seeking medical treatment? In an emergency situation, participants are encouraged to go to the nearest medical facility. Please call the local “first responder” in your locale (for example, “911” in the US, “119” in Japan, etc.). You should utilize the Assist America Website to find and record these numbers prior to your departure, or download the Assist America Phone Application, previously provided, to access them at a touch of a button. Your first priority should be to receive proper and necessary care. As soon as possible, you or someone who can represent you (trip leader, friend, family, etc.) should contact Assist using the phone numbers on your ID card or the Phone App. The assistance company serves to assist you in any way, from guaranteeing payment or providing translator services. In a non emergency situation, you are encouraged to contact Assist America for the nearest English speaking, creditable, facility. Contacting Assist America first allows their team to work with the facility to guarantee payment, expedite claims, and negotiate pricing of services rendered. What if local medical facilities are not adequate? If you are hospitalized in an area where adequate medical care is not available, we will arrange to evacuate you to a medical facility capable of providing the required care. Assist America physicians supervise every evacuation. When necessary, a medical specialist or nurse will accompany you during the evacuation. What if I need prescription medication? If you require a prescription and it cannot be obtained locally, or you need to replace lost, stolen or depleted medication, we will, subject to local regulations, arrange for the shipment of the needed medication. Please be advised that additional costs may apply. What if I am hospitalized? Call your assistance center as soon as possible. We will communicate with your treating medical provider to discuss your care and the appropriate steps for your safe and speedy recovery. Our Medical Team will monitor your condition until it has been resolved or you have safely returned home. Solutions by Assist America + + + + + + + + + + + + + + 1-800-872-1414 1-609-986-1234 [email protected]