Patriot Group Exchange Program is designed for those who are:

• Actively engaged or participating in an educational or cultural exchange program in the country of assignment through a sponsoring organization or school.
• Traveling in a group to a destination that is not the home country of any of the traveling members.

All premium rates are in U.S. dollars and are effective through 1-Nov-2010. Rates include surplus lines tax where applicable. A dependent child is a child shown on the Application Form over 14 days and under 18 years of age, traveling with the group as a dependent of a group member, and for whom premium has been paid.

Basic Short-Term Travel Plan Rates
Non-U.S. Citizens: Worldwide coverage except home country		Monthly Premium		Monthly Premium w/Optional Add-on Plan
$10,000 per illness/injury
Under age 25 years		$25.95		$27.40
25 - 49 years		$33.85		$35.70
50 - 64 years		$72.45		$76.45
U.S. Citizens: Worldwide coverage except the U.S.		Monthly Premium		Monthly Premium w/Optional Add-on Plan
$10,000 per illness/injury
Under age 25 years		$18.40		$19.40
25 - 49 years		$21.30		$22.45
50 - 64 years		$55.20		$58.25
Europe to Europe travel only		Monthly Premium		Monthly Premium w/Optional Add-on Plan
$10,000 per illness/injury
Under age 25 years		$21.85		$23.00
25 - 49 years		$25.25		$26.65
50 - 64 years		$65.50		$69.10

Standard Short-Term Travel Plan Rates
Non-U.S. Citizens:Worldwide coverage except home country		Monthly Premium		Monthly Premium w/Optional Add-on Plan
$50,000 per illness/injury
Under age 25 years		$37.10		$39.15
25 - 49 years		$48.35		$51.00
50 - 64 years		$103.50		$109.20
$250,000 per illness/injury
Under age 25 years		$46.05		$48.60
25 - 49 years		$59.95		$63.25
50 - 64 years		$128.35		$135.40
$500,000 per illness/injury
Under age 25 years		$48.55		$51.25
25 - 49 years		$74.10		$78.20
50 - 64 years		$135.40		$142.85
U.S. Citizens:Worldwide coverage except the U.S.		Monthly Premium		Monthly Premium w/Optional Add-on Plan
$50,000 per illness/injury
Under age 25 years		$26.30		$27.70
25 - 49 years		$30.40		$32.10
50 - 64 years		$78.80		$83.25
$250,000 per illness/injury
Under age 25 years		$32.60		$34.40
25 - 49 years		$37.70		$39.80
50 - 64 years		$97.85		$103.20
$500,000 per illness/injury
Under age 25 years		$34.40		$36.30
25 - 49 years		$39.80		$42.00
50 - 64 years		$103.25		$108.90
Europe to Europe travel only		Monthly Premium		Monthly Premium w/Optional Add-on Plan
$50,000 per illness/injury
Under age 25 years		$21.85		$23.00
25 - 49 years		$25.25		$26.65
50 - 64 years		$65.50		$69.10
$250,000 per illness/injury
Under age 25 years		$27.10		$28.60
25 - 49 years		$31.30		$33.05
50 - 64 years		$81.20		$85.65
$500,000 per illness/injury
Under age 25 years		$28.60		$30.15
25 - 49 years		$33.05		$34.90
50 - 64 years		$85.64		$100.40

A long-term plan is also available. For more information, please contact your independent insurance agent or International Medical Group at 1-800-628-4664.

Quality Guarantee

The group’s satisfaction is very important to IMG and the plan underwriter. If the sponsoring organization or the group is not pleased with this product for any reason, a written request may be submitted, prior to the effective date, for cancellation and refund of the premium may be submitted.

Precertification, Emergency Evacuation and Repatriation

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

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

To Report Claims

Please mail completed claim forms to International Medical Group, P.O. Box 88500, Indianapolis, IN 46208-0500 USA. All IMG contact numbers, claim forms and Certificate Wordings will be included in the fulfillment kit. IMG may also be contacted by fax: 317-655-4505 or e-mail: insurance@imglobal.com.

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