[Return to Top]
VMP Plan Benefits:
Deductible:
Your choice of US$100, $250, $500, $1,000 or $2,500 deductible
per insured person, per coverage period
Medical Maximum benefits: $25,000, $50,000, $100,000 & $250,000 ( Age 80+ $15,000 policy Maximum)
Co-insurance (After deductible paid by insured)- (See locating PPO Provider on the web sites)
Plan - A In PPO Network: The plan Pays 90% of eligible expenses up to the Policy Maximum limits.
Plan - A Out of PPO Network: Pays 70% of eligible expenses up to the Policy Maximum limits.
New Improved 100% PPO Benefits!
Plan - B In PPO Network: The plan Pays 100% of eligible expenses up to the Policy Maximum limits...
Plan - B Out of PPO Network: The plan Pays 70% of the next US$5,000 then 100% of eligible expenses up to the Max. limits.
Benefit
Period:
If a covered injury or illness requires continuing treatment
after the Period of Coverage expires, the six-month Benefit
Period may provide continued coverage. When the certificate
expires, the Company will review the date of initial treatment
for the covered injury or illness. If treatment began less
than six months before the Period of Coverage expired,
benefits for the covered injury or illness will continue
subject to the Policy Limits and the other terms of the plan
until there have been six months of continuous coverage for
the covered injury or illness.
Period of Coverage:
Minimum 10 days and maximum 12 consecutive months for any one
policy period
Emergency Evacuation:
Up to US$25,000 when coordinated through the Plan
Administrator. This Plan includes coverage for Emergency
Medical Evacuations to the nearest qualified medical facility;
expenses for reasonable travel and accommodations resulting
from the evacuation; and the cost of returning to either the
country of residence or the country where the evacuation
occurred, up to US$25,000.
Repatriation:
Up to US$20,000 per adult, US$5,000 per child when coordinated
through the Plan Administrator. If a covered illness/injury
results in death, expenses for Repatriation of bodily remains
or ashes to the country of residence will be covered up to a
maximum of US$20,000 per adult and US$5,000 per child.
Emergency
Reunion:
Up to US$15,000 when coordinated through the Plan
Administrator. This Plan provides emergency reunion coverage,
up to US$15,000 for a maximum of 15 days, for the reasonable
travel and lodging expenses of a relative or friend during an
Emergency Medical Evacuation: either the cost of accompanying
the insured during the evacuation or traveling from the
country of residence to be reunited with the insured.
Local Ambulance:
To Policy Maximum
Accidental Death and
Dismemberment: US$25,000 principal sum. The
Plan includes US$25,000 principal sum benefit for Accidental
Death and Dismemberment occurring during the Period of
Coverage: Accidental Loss of life - principal sum; -Accidental
Loss of two Members - principal sum; - Accidental Loss of one
Member - 50% of principal sum.
-Member- means hand, foot or
eye. For additional information please see the Conditions of
Coverage section.
Hospital Room and
Board: Average semi-private room rate
up to the Policy Maximum
Intensive Care:
Two times the average semi-private room rate up to the Policy
Maximum
Medical Expenses:
Usual, reasonable and customary up to the Policy Maximum
Outpatient Medical:
Usual, reasonable and customary up to the Policy Maximum
Emergency Room:
Charges incurred for the use of the Emergency Room due to an
accident are covered up to the Policy Maximum. Charges
incurred for the use of the Emergency Room for the treatment
of an illness are subject to an additional (extra) US$250
deductible if treatment does not require admittance to the
hospital.
Dental:
Injury due to an accident: The Plan covers the cost of
emergency dental treatment and dental procedures necessary to
restore sound natural teeth lost or damaged in an accident up
to the Policy Maximum.
Sudden dental pain:
The Plan will pay up to US$100 for the necessary treatment of
sudden, unexpected pain to sound natural teeth.
Returning Minor
Children: To US$5,000 when coordinated through
the Plan Administrator. If an insured person is hospitalized
due to a covered illness/ injury and is traveling alone with
child(ren) 19 or under that otherwise would be left
unattended, the Plan will pay up to US$5,000 for one way
economy fare to their home country, including a chaperone, if
necessary, for the safety of the child(ren).
Special Coverages
Incidental Home
Country Coverage: During the Period of
Coverage an insured person may return to his/her country of
residence for incidental visits up to a cumulative two weeks
total, subject to: a.
The insured person must have left their country of residence,
b. The
total Period of Coverage must be for a minimum of 30 days, and
c. The
return to the country of residence may not be taken to receive
treatment for an illness or injury incurred while traveling.
End of Trip Home
Country Coverage: For every five months of
continuous coverage you purchase, you can purchase one
additional month of home country coverage as an accommodation
and supplemental travel benefit, up to a maximum of two
months. To purchase this special home country extension
coverage, please check the appropriate box on the Application
Form, and calculate your premium to include the additional
month(s).
Trip Interruption:
To US$5,000. If, during a covered trip, there is a death of an
immediate family member (spouse, child, parent or sibling) or
the substantial destruction of the insured-s principal
residence, the Plan will pay to return the insured to the area
of principal residence. The Plan will pay for a one way air or
ground transportation ticket of the same class as the unused
travel ticket, less the value of the unused return ticket.
Lost Luggage:
To US$50 per item of personal property; maximum of US$250 per
Period of Coverage. This benefit will be paid in the event
that the Common Carrier permanently loses an insured person-s
checked luggage. This coverage is secondary to any other
available coverage, including the Carrier-s.
Common Carrier
Accidental Death: US$50,000 to Beneficiary;
maximum of US$250,000 per family. If accidental death should
occur while traveling on a commercial Common Carrier,
US$50,000 will be paid to the designated beneficiary, to a
maximum of US$250,000 per family.
Sports & Activities
Coverage: To Policy Maximum for basic sports
as described here: The Plan covers injuries incurred during
amateur athletic activities which are non-contact and engaged
in by the insured person solely for leisure, recreation,
entertainment or fitness purposes. However, activities not
covered include amateur or professional sports or other
athletic activity which is organized and/or sanctioned, or
which involves regular or scheduled practices, games or
competition.
The following hazardous activities are excluded: racing of any
kind, aviation (except when traveling as a passenger in a
commercial aircraft), BMX, BASE jumping, bobsleigh, bungee
jumping, canyoning, caving, high diving, hang gliding, heli-skiing,
hot air ballooning, inline skating, jet skiing, kayaking, luge,
motocross (moto-x), mountain biking, mountaineering,
parachuting, rappelling, rock climbing, rodeo, scuba diving,
ski jumping, sky diving, snow skiing, snowboarding,
snowmobiling, spelunking, snorkeling, surfing, wakeboarding,
water skiing, windsurfing and whitewater rafting.
[Return to Top]
VMP Plan Exclusions:
Charges for or arising from the
following services, treatments, events and/or conditions are
excluded from coverage under the plan.
1.
Pre-existing
Conditions. A pre-existing condition is defined as any injury,
illness, sickness, disease, or other physical, medical, mental
or nervous condition, disorder or ailment that, with
reasonable medical certainty, existed at the time of
application or at any time during the three years prior to the
effective date of the insurance, whether or not previously
manifested or symptomatic, diagnosed, treated, or disclosed
prior to the effective date, including any subsequent, chronic
or recurring complications or consequences related thereto or
arising therefrom.
2.
Treatment
or surgeries which are elective, investigational, experimental
or for research purposes.
3.
War,
military action, terrorism, political insurrection, protest,
or any act thereof.
4.
Immunizations
and routine physical exams.
5.
Treatment
of Temporomandibular Joint or dental treatment, except as
expressly provided for in the certificate of insurance.
6.
Venereal
disease, AIDS virus, AIDS related illness, ARC Syndrome, or
AIDS, and the cost of testing for these conditions, and
charges for treatment or surgeries which are incurred by any
Insured who was HIV+ at time of enrollment into this
insurance.
7.
Pregnancy,
childbirth, birth control, artificial insemination, treatment
for infertility or impotency, sterilization or reversal
thereof, or abortion.
8.
Injury
sustained while participating in amateur or professional
sports or other athletic activity which is organized and/or
sanctioned, or which involves regular or scheduled practices,
games or competition. The following hazardous activities are
excluded: racing of any kind, aviation (except when traveling
as a passenger in a commercial aircraft), BMX, BASE jumping,
bobsleigh, bungee jumping, canyoning, caving, high diving,
hang gliding, heli-skiing, hot air ballooning, inline skating,
jet skiing, kayaking, luge, motocross (moto-x), mountain
biking, mountaineering, parachuting, rappelling, rock
climbing, rodeo, scuba diving, ski jumping, sky diving, snow
skiing, snowboarding, snowmobiling, spelunking, snorkeling,
surfing, wakeboarding, water skiing, wind-surfing and
whitewater rafting.
9.
Vision
or ear tests and the provision of visual or hearing aids.
10.
Vocational,
recreational, speech or music therapy.
11.
Treatment
while confined primarily to receive custodial care,
educational or rehabilitative care, or nursing services.
12.
Charges,
injuries and/or illnesses resulting or arising from or
occurring during the commission or continuing perpetration of
a violation of law by the insured, including without
limitation, the engaging in an illegal occupation or act, but
excluding minor traffic violations.
13.
Treatment
for, and injuries and/or illnesses resulting or arising from,
substance abuse or drug addiction.
14.
Injury
and/or illness resulting or arising from being under the
influence of alcohol or drugs; and injury or illness resulting
from operating any type of vehicle after consuming any alcohol
or drugs.
15.
Willful
self-inflicted injury or illness.
16.
Treatment
required as a result of or arising from complications from a
treatment or condition not covered under the certificate.
17.
Any
services or supplies performed or provided by a relative of
the Insured or provided at no cost to Insured.
18.
Treatment
for mental and nervous disorders.
19.
Organ
or tissue transplants or related services.
20.
Illness
or injury where the trip to the host country is undertaken for
treatment or advice for such Illness or injury, except as
expressly provided for in the certificate of insurance.
21.
Treatment
incurred as a result of or arising from exposure to nuclear
radiation, and/or radioactive material(s)
This web
page contains only a consolidated and summary description of
all current VMP benefits, conditions, limitations and
exclusions. A certificate containing the complete Certificate
Wordings with all terms, conditions and exclusions will be
included with the fulfillment kit. IMG reserves the right to
issue the most current Certificate Wordings for this insurance
plan in the event this application and/or brochure has
expired, is modified, or is replaced with a newer version.
Current Certificate Wordings are available upon request.
[Return to Top]
Nationwide PPO Network:
Click here to ACCESS THE PPO DIRECTORY
You may
seek treatment under Patriot Travel Medical Insurance Plan
worldwide, including in the
United States
,
with the hospital or doctor of your choice. When seeking
treatment in the U.S., you may use the independent
Preferred Provider Organization (PPO) contracted by IMG, a
separately organized network (First Health Group) of
approximately 500,000 physicians and 4,700 privately owned
and operated hospitals. * This PPO network includes a
large number of hospitals including some of the most well
recognized university medical centers and transplant
facilities.
Using this provider network could significantly reduce
your out-of-pocket expenses.
PRECERTIFICATION: Each proposed hospital admission,
inpatient or outpatient surgery, and certain other medical
procedures must be Pre-certified for medical necessity.
This means the insured person or their attending physician
must call the number listed on the IMG identification card
prior to admittance to a hospital or performance of a
surgery, or medical procedure. In the case of an emergency
hospital admission, the Pre-certification call must be
made within 48 hours of the admission, or as soon as
reasonably possible. For a complete list of procedures
requiring Pre-certification, please refer to your
certificate wording. If Pre-certification guidelines are
not followed, eligible claims and expenses will be reduced
by 50%.
[Return to Top]
Rates: VMP Plan Monthly/Daily Rates:
|
PLAN A
VMP MONTHLY RATES
90%/10% in PPO Network up to the Policy Maximum after deductible
met (Options 1, 2, 3, 4)
(70%/30% out of PPO Network)
|
|
PLAN A
VMP DAILY RATES
(10 day minimum)
90%/10% in PPO Network up to the
Policy Maximum after deductible met (Options 1, 2, 3,4)
(70%/30% out of PPO Network)
|
|
Option 1 -US$25,000 Policy Limit |
|
Deductible
|
US$100
|
US$250
|
US$500
|
US$1,000
|
US$2,500
|
|
Under 18
|
$23
|
$21
|
$19
|
$17
|
$14
|
|
18 - 29
|
$36
|
$33
|
$30
|
$26
|
$23
|
|
30 - 39
|
$46
|
$42
|
$38
|
$34
|
$30
|
|
40 - 49
|
$71
|
$65
|
$57
|
$52
|
$46
|
|
50 - 59
|
$101
|
$92
|
$84
|
$73
|
$65
|
|
60 - 64
|
$127
|
$116
|
$106
|
$94
|
$81
|
|
65 - 69
|
$146
|
$133
|
$120
|
$107
|
$94
|
|
70 - 79
|
$196
|
$178
|
$159
|
$143
|
$124
|
|
80+*
|
$371
|
$337
|
$305
|
$269
|
$237
|
|
*$15,000
policy maximum |
|
|
|
Option 1 -US$25,000 Policy Limit |
|
Deductible
|
US$100
|
US$250
|
US$500
|
US$1,000
|
US$2,500
|
|
Under 18
|
$0.77
|
$0.70
|
$0.64
|
$0.58
|
$0.46
|
|
18 - 29
|
$1.20
|
$1.09
|
$1.00
|
$0.88
|
$0.76
|
|
30 - 39
|
$1.53
|
$1.40
|
$1.27
|
$1.12
|
$1.00
|
|
40 - 49
|
$2.37
|
$2.15
|
$1.91
|
$1.73
|
$1.52
|
|
50 - 59
|
$3.37
|
$3.06
|
$2.79
|
$2.43
|
$2.15
|
|
60 - 64
|
$4.24
|
$3.85
|
$3.52
|
$3.12
|
$2.70
|
|
65 - 69
|
$4.87
|
$4.43
|
$4.00
|
$3.58
|
$3.12
|
|
70 - 79
|
$6.54
|
$5.95
|
$5.31
|
$4.76
|
$4.13
|
|
80+*
|
$12.37
|
$11.23
|
$10.17
|
$8.97
|
$7.90
|
|
*$15,000
policy maximum |
|
|
Option 2 -US$50,000 Policy Limit |
|
Deductible
|
US$100
|
US$250
|
US$500
|
US$1,000
|
US$2,500
|
|
Under 18
|
$25
|
$23
|
$21
|
$19
|
$15
|
|
18 - 29
|
$40
|
$36
|
$33
|
$29
|
$25
|
|
30 - 39
|
$51
|
$46
|
$42
|
$37
|
$33
|
|
40 - 49
|
$78
|
$71
|
$63
|
$57
|
$50
|
|
50 - 59
|
$111
|
$101
|
$92
|
$80
|
$71
|
|
60 - 64
|
$140
|
$127
|
$116
|
$103
|
$89
|
|
65 - 69
|
$161
|
$146
|
$132
|
$118
|
$103
|
|
70 - 79
|
$215
|
$196
|
$175
|
$157
|
$136
|
|
80+*
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
|
|
|
Option 2 -US$50,000 Policy Limit |
|
Deductible
|
US$100
|
US$250
|
US$500
|
US$1,000
|
US$2,500
|
|
Under 18
|
$0.84
|
$0.77
|
$0.70
|
$0.63
|
$0.50
|
|
18 - 29
|
$1.32
|
$1.20
|
$1.10
|
$0.97
|
$0.83
|
|
30 - 39
|
$1.69
|
$1.53
|
$1.40
|
$1.23
|
$1.10
|
|
40 - 49
|
$2.60
|
$2.37
|
$2.10
|
$1.90
|
$1.67
|
|
50 - 59
|
$3.70
|
$3.37
|
$3.07
|
$2.67
|
$2.37
|
|
60 - 64
|
$4.66
|
$4.23
|
$3.87
|
$3.43
|
$2.97
|
|
65 - 69
|
$5.37
|
$4.87
|
$4.40
|
$3.93
|
$3.43
|
|
70 - 79
|
$7.17
|
$6.53
|
$5.83
|
$5.23
|
$4.53
|
|
80+*
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
|
|
Option 3 -US$100,000 Policy Limit |
|
Deductible
|
US$100
|
US$250
|
US$500
|
US$1,000
|
US$2,500
|
|
Under 18
|
$29
|
$26
|
$24
|
$22
|
$18
|
|
18 - 29
|
$46
|
$42
|
$38
|
$34
|
$30
|
|
30 - 39
|
$62
|
$56
|
$50
|
$44
|
$40
|
|
40 - 49
|
$88
|
$80
|
$72
|
$64
|
$56
|
|
50 - 59
|
$136
|
$124
|
$112
|
$100
|
$86
|
|
60 - 64
|
$174
|
$158
|
$143
|
$126
|
$110
|
|
65 - 69
|
$210
|
$190
|
$171
|
$152
|
$134
|
|
70 - 79
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
|
80+*
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
|
|
|
Option 3 -US$100,000 Policy Limit |
|
Deductible
|
US$100
|
US$250
|
US$500
|
US$1,000
|
US$2,500
|
|
Under 18
|
$0.95
|
$0.87
|
$0.80
|
$0.73
|
$0.60
|
|
18 - 29
|
$1.54
|
$1.40
|
$1.27
|
$1.13
|
$1.00
|
|
30 - 39
|
$2.05
|
$1.87
|
$1.67
|
$1.47
|
$1.33
|
|
40 - 49
|
$2.93
|
$2.67
|
$2.40
|
$2.13
|
$1.87
|
|
50 - 59
|
$4.55
|
$4.13
|
$3.73
|
$3.33
|
$2.87
|
|
60 - 64
|
$5.80
|
$5.27
|
$4.77
|
$4.20
|
$3.67
|
|
65 - 69
|
$7.00
|
$6.33
|
$5.70
|
$5.07
|
$4.47
|
|
70 - 79
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
|
80+*
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
|
|
Option 4 -US$250,000 Policy Limit |
|
Deductible
|
US$100
|
US$250
|
US$500
|
US$1,000
|
US$2,500
|
|
Under 18
|
$33
|
$30
|
$28
|
$24
|
$20
|
|
18 - 29
|
$64
|
$58
|
$52
|
$46
|
$40
|
|
30 - 39
|
$79
|
$72
|
$66
|
$58
|
$50
|
|
40 - 49
|
$117
|
$106
|
$94
|
$84
|
$74
|
|
50 - 59
|
$183
|
$166
|
$150
|
$132
|
$116
|
|
60 - 64
|
$231
|
$210
|
$190
|
$169
|
$147
|
|
65 - 69
|
$269
|
$244
|
$221
|
$195
|
$171
|
|
70 - 79
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
|
80+*
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
|
|
|
Option 4 -US$250,000 Policy Limit |
|
Deductible
|
US$100
|
US$250
|
US$500
|
US$1,000
|
US$2,500
|
|
Under 18
|
$1.10
|
$1.00
|
$0.93
|
$0.80
|
$0.67
|
|
18 - 29
|
$2.13
|
$1.93
|
$1.73
|
$1.53
|
$1.33
|
|
30 - 39
|
$2.64
|
$2.40
|
$2.20
|
$1.93
|
$1.67
|
|
40 - 49
|
$3.89
|
$3.53
|
$3.13
|
$2.80
|
$2.47
|
|
50 - 59
|
$6.09
|
$5.53
|
$5.00
|
$4.40
|
$3.87
|
|
60 - 64
|
$7.70
|
$7.00
|
$6.33
|
$5.63
|
$4.90
|
|
65 - 69
|
$8.97
|
$8.13
|
$7.37
|
$6.50
|
$5.70
|
|
70 - 79
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
|
80+*
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
|
|
|
|
|
PLAN B
100% in PPO Network up to the Policy Maximum Limit after deductible met (Options 5,6,7,8) (70% of next$5,000 and then 100% out of PPO Network)
|
|
PLAN B
100% in PPO Network up to the Policy Maximum Limit after deductible met (Options 5,6,7,8) (70% of next$5,000 and then 100% out of PPO Network)
|
|
Option 5 -US$25,000 Policy Limit |
|
Deductible
|
US$100
|
US$250
|
US$500
|
US$1,000
|
US$2,500
|
|
Under 18
|
$30
|
$27
|
$25
|
$22
|
$19
|
|
18 - 29
|
$46
|
$42
|
$38
|
$33
|
$29
|
|
30 - 39
|
$59
|
$54
|
$48
|
$43
|
$38
|
|
40 - 49
|
$90
|
$82
|
$74
|
$66
|
$57
|
|
50 - 59
|
$129
|
$117
|
$106
|
$94
|
$82
|
|
60 - 64
|
$163
|
$148
|
$133
|
$119
|
$104
|
|
65 - 69
|
$186
|
$169
|
$152
|
$135
|
$118
|
|
70 - 79
|
$252
|
$229
|
$206
|
$183
|
$161
|
|
80+*
|
$480
|
$436
|
$392
|
$349
|
$305
|
|
*$15,000 policy maximum |
|
|
|
Option 5 -US$25,000 Policy Limit |
|
Deductible
|
US$100
|
US$250
|
US$500
|
US$1,000
|
US$2,500
|
|
Under 18
|
$1.00
|
$0.91
|
$0.82
|
$0.73
|
$0.64
|
|
18 - 29
|
$1.53
|
$1.40
|
$1.26
|
$1.12
|
$0.98
|
|
30 - 39
|
$1.97
|
$1.79
|
$1.61
|
$1.43
|
$1.25
|
|
40 - 49
|
$3.00
|
$2.73
|
$2.46
|
$2.18
|
$1.91
|
|
50 - 59
|
$4.30
|
$3.91
|
$3.52
|
$3.13
|
$2.74
|
|
60 - 64
|
$5.44
|
$4.94
|
$4.45
|
$3.96
|
$3.46
|
|
65 - 69
|
$6.21
|
$5.64
|
$5.08
|
$4.51
|
$3.95
|
|
70 - 79
|
$8.41
|
$7.64
|
$6.88
|
$6.12
|
$5.35
|
|
80+*
|
$16.00
|
$14.53
|
$13.08
|
$11.63
|
$10.17
|
|
*$15,000 policy maximum |
|
|
Option 6 -US$50,000 Policy Limit |
|
Deductible
|
US$100
|
US$250
|
US$500
|
US$1,000
|
US$2,500
|
|
Under 18
|
$33
|
$30
|
$27
|
$24
|
$21
|
|
18 - 29
|
$51
|
$46
|
$41
|
$37
|
$32
|
|
30 - 39
|
$65
|
$59
|
$53
|
$47
|
$41
|
|
40 - 49
|
$99
|
$90
|
$81
|
$72
|
$63
|
|
50 - 59
|
$142
|
$129
|
$116
|
$103
|
$90
|
|
60 - 64
|
$179
|
$163
|
$147
|
$130
|
$114
|
|
65 - 69
|
$205
|
$186
|
$167
|
$149
|
$130
|
|
70 - 79
|
$277
|
$252
|
$227
|
$202
|
$176
|
|
80+*
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
|
*$15,000 policy maximum |
|
|
|
Option 6 -US$50,000 Policy Limit |
|
Deductible
|
US$100
|
US$250
|
US$500
|
US$1,000
|
US$2,500
|
|
Under 18
|
$1.10
|
$1.00
|
$0.90
|
$0.80
|
$0.70
|
|
18 - 29
|
$1.69
|
$1.53
|
$1.38
|
$1.23
|
$1.07
|
|
30 - 39
|
$2.16
|
$1.97
|
$1.77
|
$1.57
|
$1.38
|
|
40 - 49
|
$3.30
|
$3.00
|
$2.70
|
$2.40
|
$2.10
|
|
50 - 59
|
$4.73
|
$4.30
|
$3.87
|
$3.44
|
$3.01
|
|
60 - 64
|
$5.98
|
$5.43
|
$4.89
|
$4.35
|
$3.80
|
|
65 - 69
|
$6.82
|
$6.20
|
$5.58
|
$4.96
|
$4.34
|
|
70 - 79
|
$9.24
|
$8.40
|
$7.56
|
$6.72
|
$5.88
|
|
80+*
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
|
*$15,000 policy maximum |
|
|
Option 7 -US$100,000 Policy Limit |
|
Deductible
|
US$100
|
US$250
|
US$500
|
US$1,000
|
US$2,500
|
|
Under 18
|
$36
|
$33
|
$30
|
$26
|
$23
|
|
18 - 29
|
$58
|
$53
|
$48
|
$42
|
$37
|
|
30 - 39
|
$76
|
$69
|
$62
|
$55
|
$48
|
|
40 - 49
|
$111
|
$101
|
$91
|
$81
|
$71
|
|
50 - 59
|
$172
|
$156
|
$140
|
$125
|
$109
|
|
60 - 64
|
$218
|
$198
|
$178
|
$158
|
$139
|
|
65 - 69
|
$262
|
$238
|
$214
|
$190
|
$167
|
|
70 - 79
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
|
80+*
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
|
|
|
Option 7 -US$100,000 Policy Limit |
|
Deductible
|
US$100
|
US$250
|
US$500
|
US$1,000
|
US$2,500
|
|
Under 18
|
$1.21
|
$1.10
|
$0.99
|
$0.88
|
$0.77
|
|
18 - 29
|
$1.94
|
$1.77
|
$1.59
|
$1.41
|
$1.24
|
|
30 - 39
|
$2.53
|
$2.30
|
$2.07
|
$1.84
|
$1.61
|
|
40 - 49
|
$3.70
|
$3.37
|
$3.03
|
$2.69
|
$2.36
|
|
50 - 59
|
$5.72
|
$5.20
|
$4.68
|
$4.16
|
$3.64
|
|
60 - 64
|
$7.26
|
$6.60
|
$5.94
|
$5.28
|
$4.62
|
|
65 - 69
|
$8.73
|
$7.93
|
$7.14
|
$6.35
|
$5.55
|
|
70 - 79
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
|
80+*
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
|
|
Option 8 -US$250,000 Policy Limit |
|
Deductible
|
US$100
|
US$250
|
US$500
|
US$1,000
|
US$2,500
|
|
Under 18
|
$43
|
$39
|
$35
|
$31
|
$27
|
|
18 - 29
|
$80
|
$73
|
$66
|
$58
|
$51
|
|
30 - 39
|
$101
|
$92
|
$83
|
$74
|
$64
|
|
40 - 49
|
$147
|
$134
|
$121
|
$107
|
$94
|
|
50 - 59
|
$232
|
$211
|
$190
|
$169
|
$148
|
|
60 - 64
|
$295
|
$268
|
$241
|
$214
|
$188
|
|
65 - 69
|
$344
|
$313
|
$282
|
$250
|
$219
|
|
70 - 79
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
|
80+*
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
|
|
|
Option 8 -US$250,000 Policy Limit |
|
Deductible
|
US$100
|
US$250
|
US$500
|
US$1,000
|
US$2,500
|
|
Under 18
|
$1.43
|
$1.30
|
$1.17
|
$1.04
|
$0.91
|
|
18 - 29
|
$2.68
|
$2.43
|
$2.19
|
$1.95
|
$1.70
|
|
30 - 39
|
$3.37
|
$3.07
|
$2.76
|
$2.45
|
$2.15
|
|
40 - 49
|
$4.91
|
$4.47
|
$4.02
|
$3.57
|
$3.13
|
|
50 - 59
|
$7.74
|
$7.03
|
$6.33
|
$5.63
|
$4.92
|
|
60 - 64
|
$9.83
|
$8.93
|
$8.04
|
$7.15
|
$6.25
|
|
65 - 69
|
$11.48
|
$10.43
|
$9.39
|
$8.35
|
$7.30
|
|
70 - 79
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
|
80+*
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
|
| |
|
Rates include 2.5% surplus lines tax where applicable.
A dependent child is your child shown on the Application Form
over 14 days andUnder 18 years of age, traveling with you,
and for whom premium has been paid. |
