Summary of Plan Benefits

Important Plan Information

This document provides only a summary of the Plan Benefits. This document Product: Standard Plan
is not Your Purchase Confirmation. Your Purchase Confirmation and Plan #: N300S
applicable Plan Documents are provided to You at time of purchase.

Satisfaction Guarantee
If You are not satisfied for any reason, You may return Your Plan Documents Schedule of Benefits - N300S
to us within 10 days after receipt. Your plan payment will be refunded, Confirmation of Coverage
provided You have not filed a claim or departed on Your Trip. When so Plan Benefits Maximum Benefit Amount
returned, the Plan Documents are void from the beginning.
Trip Cancellation...................................................Up To Trip Cost *
One Call Worldwide Travel Services Network Single Occupancy........................................................Included
One Call Travel Services Network provides: medical, legal and travel assistance Trip Interruption....................................................Up To Trip Cost *
services available 24 hours a day/365 days a year. A complete list of these
services is included in Your Plan Documents. To contact One Call: Trip Delay (Up to $250 Per Day).............................................$500
Within U.S.A. & Canada Outside U.S.A. & Canada Accidental Death and Dismemberment..............................$5,000
1-855-878-9588 1-603-328-1329 Medical Expense/Emergency Evacuation
Emergency Accident or Sickness Medical Expense....$100,000
This document provides a brief summary of the plan. If there is a conflict
between this document and a plan provision, the plan provision shall prevail. Emergency Evacuation or Repatriation of Remains....$300,000
Emergency Dental Treatment.............................................$750
Hospital Advancement........................................................$500
Baggage/Personal Effects...................................................$1,000
Per Article Limit..................................................................$500
Combined Maximum Limit..................................................$500**
Baggage Delay (Up to $150 Per Day).....................................$750

* Trip Cost up to a maximum of $2,500

** Applies to: jewelry; watches; articles consisting in whole or in part of silver,
gold or platinum; furs; articles trimmed with or made mostly of fur.

Non-Insurance Services
One Call 24-Hour Assistance Services
Global Xpi Medical Records Service
Non-Insurance Services

The Travel Insurance Benefits of this Plan are Underwritten By:

Nationwide Mutual Insurance Company
Please Note: This Plan is only effective for You if the required plan payment
for the Covered Trip has been paid prior to Your Scheduled Departure Date for
Your Covered Trip. Plan provisions and benefits may vary by state jurisdiction.
Please refer to Your Plan Documents for complete details.

SRTC 2500 VA
 Travel Protection Plan Customer Service and Claims
Plan Documents
for Standard Plan # N300S Have questions or need to report a claim? You can call us
toll-free at the number listed below. You can also view many
Frequently Asked Questions, report and complete your claim(s)
online at www.tripmate.com or call 1-844-207-1930.

Benefits are administered by:

Trip Mate, Inc. (in CA & UT, dba Trip Mate Insurance Agency)
9225 Ward Parkway, Suite 200, Kansas City, MO, 64114,
Tel: 1-844-207-1930.

YOUR PLAN NUMBER: N300S

One Call
Worldwide Travel Services Network

Multi-lingual professionals are available 24 hours a day to

provide help, advice and referrals for medical emergencies. We
will help you locate local physicians, dentists, or medical facilities,
and provide services for:
• Medical Consultation and Monitoring
• Medical Evacuation Arrangements
• Emergency Medical Payments
• Prescription Assistance
• Repatriation of Remains
• 24 Hour Legal Assistance
• Nurse Helpline
• Message Services
• Language Interpretation Services
• Emergency Cash Transfer
• Pre-Trip Travel Services
• Travel Document and Ticket Replacement
A complete list of these services is included in your
certificate/policy. To contact One Call:
Our Travel Protection Plan helps to protect
Within U.S.A. & Canada Outside U.S.A. & Canada
Your travel investment, Your belongings and
1-855-878-9588 1-603-328-1329
most importantly You for those unforeseen
circumstances that arise before or during
24 Hour Assistance Service is provided by: One Call Travel
Your Trip. Services Network.

ACCESS YOUR MEDICAL RECORDS ONLINE

With Global Xpi, you can relax knowing your important medical
records are available to you or any Physician chosen by you,
at anytime, anywhere in the world, wherever internet access is
available. Register at www.globalxpi.com or call, toll free:
1-800-379-9887 Use Program Code N300S
These Services are Provided by: Global Xpi, a Trip Mate brand.
 NATIONWIDE MUTUAL INSURANCE COMPANY
PASSENGER PROTECTION INSURANCE POLICY

GENERAL DEFINITIONS
“Accident” means a sudden, unexpected, unusual, specific event that
occurs at an identifiable time and place, but shall also include exposure
Nationwide Mutual Insurance Company
resulting from a mishap to a conveyance in which You are traveling.
One Nationwide Plaza
MR-05-10 “Accidental Injury” means Bodily Injury caused by an accident (of external
Columbus, Ohio 43215 origin) being the direct and independent cause in the loss.
800-882-2822 “Actual Cash Value” means purchase price less depreciation.
This Certificate of Coverage describes all of the travel insurance benefits, “Additional Expense” means any reasonable expenses for meals and
underwritten by Nationwide Mutual Insurance Company and herein lodging which were necessarily incurred as the result of a Hazard and which
referred to as the Company, and assistance services provided by One were not provided by the Common Carrier or other party free of charge.
Call International. The insurance benefits and assistance services vary
from program to program. Please refer to the accompanying Confirmation “Bankruptcy” means the filing of a petition for voluntary or involuntary
of Coverage. It provides You with specific information about the program bankruptcy in a court of competent jurisdiction under Chapter 7 or Chapter
You purchased. Please contact the Plan Administrator immediately if You 11 of the United States Bankruptcy Code 11 L.S.C. Subsection 101 et seq.
believe that the Confirmation of Coverage is incorrect. “Bodily Injury” means identifiable physical injury which: is caused by an
This Certificate of Coverage is issued in consideration of the enrollment Accident and is independent of disease or bodily infirmity.
form and payment of any premium due. All statements in the enrollment “Business Partner” means an individual who: (a) is involved in a legal
forms are representations and not warranties. Only statements contained partnership; and (b) is actively involved in the day-to-day management of
in a written enrollment form will be used to void insurance, reduce benefits the business.
or defend a claim.
“Checked Baggage” means a piece of baggage for which a claim check
All premium is non-refundable after a 10 day review period. In the event the has been issued to You by a Common Carrier.
premium paid for coverage is less than the required premium for coverage,
“Common Carrier” means any land, sea, and/or air conveyance operating
benefits will be paid in direct proportion of the actual amount paid to the
under a valid license for the transportation of passengers for hire.
required premium due.
“Company” means Nationwide Mutual Insurance Company.
NO DIVIDENDS WILL BE PAYABLE UNDER THE GROUP POLICY.
“Covered Expenses” shall mean expenses incurred by You which are for
The President and Secretary of Nationwide Mutual Insurance Company medically necessary services, supplies, care, or treatment; due to Illness
witness this Policy. or Injury; prescribed, performed or ordered by a Physician; reasonable
and customary charges; incurred while insured under the Group Policy;
Secretary President and which do not exceed the maximum limits shown in the Confirmation of
Coverage, under each stated benefit.
“Covered Trip” means any class of scheduled trips, tours or cruises You
request coverage and remit the required premium.
“Cruise” means any prepaid sea arrangements made by the Participating
TRAVEL PROTECTION CERTIFICATE Organization.
EXCESS INSURANCE “Default” means a material failure or inability to provide contracted services
due to Financial Insolvency.
TABLE OF CONTENTS “Dependent Child(ren)” means Your child (or children), including an
GENERAL DEFINITIONS unmarried child, stepchild, legally adopted child or foster child who is:
GENERAL PROVISIONS (1) less than age 19 and primarily dependent on You for support and
COVERAGES: maintenance; or (2) who is at least age 19 but less than age 23 and who
Trip Cancellation regularly attends an accredited school or college; and who is primarily
Trip Interruption dependent on You for support and maintenance.
Trip Delay “Domestic Partner” means a person who is at least 18 years of age
Accidental Death & Dismemberment with whom You reside and can show evidence of cohabitation and shared
Emergency Accident Medical Expense financial assets and obligations for at least the previous six months and
Emergency Sickness Medical Expense has an affidavit of domestic partnership, if recognized by the jurisdiction
Emergency Evacuation within which You reside.
Repatriation of Remains “Economy Fare” means the lowest published rate for a round trip
Baggage/Personal Effects economy ticket.
Baggage Delay
“Effective Date” means the date and time Your coverage begins, as
LIMITATIONS AND EXCLUSIONS
outlined in the General Provisions section of this Certificate.
COORDINATION OF BENEFITS
“Exotic Vehicles” includes Alfa Romeo, Aston Martin, Auburn, Avanti, Bentley,
Bertone, BMC/Leyland, BMW M Series, Bradley, Bricklin, Cosworth, Citroen,
Clenet, De Lorean, Excalibre, Ferrari, Fiat, Iso, Jaguar, Jensen, Jensen
Healy, Lamborghini, Lancia, Lotus, Maserati, MG, Morgan, Pantera, Panther,
Pininfarina, Rolls Royce, Rover, Stutz, Sterling, Triumph, TVR and Yugo.

SRTC 2500 VA 05-17 -1-

“Family Member” means Your or Your Traveling Companion’s legal “Payments or Deposits” means the cash, check, or credit card amounts
or common law spouse, ex-spouse, parent, legal guardian, step-parent, actually paid for Your Covered Trip. Payments made in the form of a certificate,
grandparent, parents-in-law, grandchild, natural or adopted child, step-child, voucher or discount are not Payments or Deposits as defined herein.
children-in-law, brother, sister, step-brother, step-sister, brother-in-law, sister- “Physician” means a licensed practitioner of medical, surgical or dental
in-law, aunt, uncle, niece or nephew, Business Partner or Domestic Partner. services acting within the scope of his/her license. The treating Physician
“Financial Insolvency” means the total cessation of operations due may not be You, a Traveling Companion or a Family Member.
to insolvency, with or without the filing of a Bankruptcy petition by a tour “Pre-Existing Condition” means an illness, disease, or other condition
operator, cruise line, or airline provided the Financial Insolvency occurs during the 90 day period immediately prior to the Effective Date for which You,
more than 15 days following the Effective Date. There is no coverage for a Traveling Companion Family Member booked to travel with You: 1) exhibited
the Financial Insolvency of any person, organization, agency or firm from symptoms which would have caused one to seek care or treatment; or 2)
whom You purchased travel arrangements supplied by others. received or received a recommendation for a test, examination, or medical
“Hazard” means: treatment or 3) took or received a prescription for drugs or medicine.
(a) Any delay of a Common Carrier (including Inclement Weather). Item (3) of this definition does not apply to a condition which is treated or
(b) Any delay by a traffic accident en route to a departure, in which You or controlled solely through the taking of prescription drugs or medicine and
a Traveling Companion is not directly involved. remains treated or controlled without any adjustment or change in the required
prescription throughout the 90 day period before the Effective Date.
(c) Any delay due to lost or stolen passports, travel documents or money,
quarantine, hijacking, unannounced strike, natural disaster, civil “Scheduled Departure Date” means the date on which You are originally
commotion or riot; scheduled to leave on the Trip.

d) A closed roadway causing cessation of travel to the destination of the “Scheduled Return Date” means the date on which You are originally
Covered Trip (substantiated by the department of transportation, state scheduled to return to the point of origin or to a different final destination.
police, etc.) “Sickness” means an illness or disease of the body which: 1) requires
“Hospital” means a facility that: a physical examination and medical treatment by a Physician and 2)
commences while Your coverage is in effect. An illness or disease of the
(a) holds a valid license if it is required by the law; body which begins prior to the Effective Date of coverage is not a Sickness
(b) operates primarily for the care and treatment of sick or injured persons as defined herein and is not covered by the policy unless it suddenly
as in-patients; worsens or becomes acute after the Effective Date.
(c) has a staff of one or more Physicians available at all times; “Strike” means any unannounced labor disagreement that interferes with
the normal departure and arrival of a Common Carrier.
(d) provides 24 hour nursing service and has at least one registered
professional nurse on duty or call; “Terrorist Attack” means an act of violence, other than civil commotion,
insurrection or riot (that is not an act of war, declared or undeclared), that
(e) has organized diagnostic and surgical facilities, either on the premises results in loss of life or major damage to property, by any person acting
or in facilities available to the hospital on a pre-arranged basis; and on behalf of, or in connection with, any organization which is generally
(f) is not, except incidentally, a clinic, nursing home, rest home, or recognized as having the intent to overthrow or influence the control of any
convalescent home for the aged, or similar institution. government.
“Inclement Weather” means any severe weather condition that delays the “Travel Arrangements” means: (a) transportation; (b) accommodations;
scheduled arrival or departure of a Common Carrier. and (c) other specified services arranged by the Travel Supplier for the
Covered Trip.
“Individual Coverage Term” means the period of time beginning when you
have been enrolled for coverage under the Group Policy and for whom the “Traveling Companion” means a person or persons with whom You have
required premium has been paid. coordinated travel arrangements and intends to travel with during the
Covered Trip. Note, a group or tour leader is not considered a Traveling
“Insured” means the person who has enrolled for and paid for coverage
Companion unless You are sharing room accommodations with the group
under the Group Policy.
or tour leader.
“Land/Sea Arrangements” means land and/or sea arrangements made
“Travel Supplier” means tour operator, cruise line, airline, hotel, travel
by the Participating Organization.
agency, etc. who has made the land and/or sea arrangements.
“Loss” means injury or damage sustained by You in consequence of
“Trip” means any class of scheduled trips, tours or cruises for which You
happening of one or more of the occurrences against which the Company
request coverage and remit the required plan payment.
has undertaken to indemnify You.
“You or Your” refers to all persons listed on the Confirmation of Coverage
“Maximum Benefit” means the largest total amount of Covered Expenses
under the program purchased by You.
that the Company will pay for Your covered losses.
“Medically Necessary” means a service or supply which: (a) is
recommended by the attending Physician; (b) is appropriate and consistent GENERAL PROVISIONS
with the diagnosis in accord with accepted standards of community
practice; (c) could not have been omitted without adversely affecting Your The following provisions apply to all coverages:
condition or quality of medical care; (d) is delivered at the most appropriate WHEN YOUR COVERAGE BEGINS – Provided:
level of care and not primarily for the sake of convenience; and (e) is not
considered experimental unless coverage for experimental services or (a) coverage has been elected; and
supplies is required by law. (b) the required premium has been paid,
“Participating Organization” means a travel agency, tour operator, cruise
line, airline or other organization that applies for coverage under the Group
Policy and remits the required premium to the Company.

SRTC 2500 VA -2-

All coverage (except Trip Cancellation) will begin at 12:01 A.M. local time CONTROLLING LAW – Any part of the Group Policy that conflicts with the
at Your location on the Scheduled Departure Date; or the actual departure state law where the Group Policy is issued is changed to meet the minimum
date if change is required by a Common Carrier, when You depart for the first requirements of that law.
Travel Arrangement. If coverage is purchased on the Scheduled Departure
SUBROGATION – To the extent the Company pays for a loss suffered by
Date, such coverage will take effect at 12:01 A.M. local time, at Your location,
You, the Company will take over the rights and remedies You had relating
on the day after the Scheduled Departure Date.
to the loss. This is known as subrogation. You must help the Company
Trip Cancellation coverage will begin on Your Effective Date. to preserve its rights against those responsible for the loss. This may
WHEN YOUR COVERAGE ENDS – Your coverage will end at 11:59 involve signing any papers and taking any other steps the Company may
P.M., local time on the date that is the earliest of the following: reasonably require. If the Company takes over Your rights, You must sign
an appropriate subrogation form supplied by the Company.
(a) the Scheduled Return Date as stated on the travel tickets;
The following provisions will apply to Trip Cancellation, Trip Interruption, Trip
(b) the date You return to Your origination point if prior to the Scheduled Delay, Accidental Death & Dismemberment, Emergency Sickness Medical
Return Date; Expense, Emergency Accident Medical Expense, Emergency Evacuation,
(c) the date You leave or change Your Covered Trip (unless due to and Repatriation of Remains:
unforeseen and unavoidable circumstances covered by the Policy); PAYMENT OF CLAIMS – The Company, or its designated representative,
(d) the time the Group Policy terminates. If insurance was purchased prior will pay a claim after receipt of acceptable proof of loss. Benefits for loss
to the termination, insurance will continue to the end of the Individual of life are payable to Your beneficiary. If a beneficiary is not otherwise
Coverage Term; designated by You, benefits for loss of life will be paid to the first of the
following surviving preference beneficiaries:
(e) The date You cancel the Covered Trip;
(a) Your spouse:
(f) When You are less than 100 miles from Your primary residence;
(b) Your child or children jointly:
(g) Any Trip that exceeds 365 days.
(c) Your parents jointly if both are living or the surviving parent if only one
EXTENDED COVERAGE – Coverage will be extended under the following survives:
conditions:
(a) If You are a passenger on a scheduled common carrier that is (d) Your brothers and sisters jointly: or
unavoidably delayed in reaching the final destination coverage will be (e) Your estate.
extended for the period of time needed to arrive at the final destination; All other claims will be paid to You. In the event You are a minor, incompetent
(b) If You are unavoidably delayed in traveling on the Scheduled Return or otherwise unable to give a valid release for the claim, the Company may
Date due to a reason covered under this policy/certificate, benefits make arrangement to pay claims to Your legal guardian, committee or other
will be extended for the period of time needed to arrive at the point of qualified representative.
origin or to a different final destination;
All or a portion of all other benefits provided by the Group Policy may, at the
(c) If: (a) Your entire Covered Trip is covered by the policy/certificate; and option of the Company, be paid directly to the provider of the service(s). All
(b) Your return is delayed by an event specified under Trip Cancellation benefits not paid to the provider will be paid to You.
and Interruption or Trip Delay. This extension of coverage will end on the
earlier of: (a) the date You reach Your return destination; or (b) seven (7) Any payment made in good faith will discharge the Company’s liability to
days after the date the Covered Trip was scheduled to be completed. the extent of the claim.
In no event will coverage be extended for unscheduled extensions to Your The applicable benefit amount will be reduced by the amount of benefits, if
Covered Trip for which premium has not been paid in advance. any, previously paid by other Insurance Policies. In no event will the Company
reimburse You for an amount greater than the amount paid by You.
ARBITRATION – Notwithstanding anything in this Policy to the contrary,
any claim arising out of or relating to this contract, or its breach, will NOTICE OF CLAIM – Written notice of claim must be given by the Claimant
be settled by arbitration administered by the American Arbitration (either You or someone acting for You) to the Company or its designated
Association in accordance with the Uniform Arbitration Act (710 ILCS 5/1 representative within twenty (20) days after a covered loss first begins
et seq. except to the extent provided otherwise in this clause. Judgment or as soon as reasonably possible. Notice should include Your name, the
upon the award rendered in such arbitration may be entered in any court Participating Organization’s name and the Group Policy number. Notice
having jurisdiction thereof. All fees and expenses of the arbitration shall be should be sent to the Company’s administrative office, at the address
borne by the parties equally. However, each party will bear the expense shown on the cover page of the Group Policy, or to the Company’s
of its own counsel, experts, witnesses, and preparation and presentation designated representative.
of proofs. The arbitrators are precluded from awarding punitive, treble or PROOF OF LOSS – The Claimant must send the Company, or its designated
exemplary damages, however so denominated. If more than one Insured is representative, proof of loss within ninety (90) days after a covered loss
involved in the same dispute arising out of the same Policy and relating to occurs or as soon as reasonably possible.
the same loss or claim, all such Insureds will constitute and act as one party
PHYSICAL EXAMINATION AND AUTOPSY – The Company, or its designated
for the purposes of the arbitration. Such arbitration will be voluntary,
representative, at their own expense, have the right to have You examined
will be by mutual consent by all parties, and may be binding upon all
as often as reasonable necessary while a claim is pending. The Company,
parties or non-binding on the Insured. Nothing in this clause will be
or its designated representative, also has the right to have an autopsy made
construed to impair the rights of the Insureds to assert several, rather
unless prohibited by law.
than joint, claims or defenses.
TIME OF PAYMENT OF CLAIMS: Benefits payable under this policy for any
LEGAL ACTIONS – No legal action for a claim can be brought against the
loss other than loss for which this policy provides any periodic payment will
Company until sixty (60) days after the Company receives proof of loss.
be paid immediately upon receipt of due written proof of such loss. Subject to
No legal action for a claim can be brought against the Company more than
due written proof of loss, all accrued indemnities for loss for which this policy
three (3) years after the time required for giving proof of loss.
provides periodic payment will be paid monthly and any balance remaining
unpaid upon the termination of liability, will be paid immediately upon receipt
of due written proof.

SRTC 2500 VA -3-

All claims shall be paid within 30 days following receipt by the Company of c) A Terrorist Attack (or Attacks) occurs in Your departure city or in a city
due proof of loss. Failure to pay within such period shall entitle the claimant that is still a scheduled destination for Your Covered Trip, provided:
to interest at the rate of 9 percent per annum from the 30th day after receipt the Terrorist Attack (or Attacks) occurs within thirty (30) days of
of such proof of loss to the date of late payment, provided that interest the scheduled departure date for Your Covered Trip or during Your
amounting to less than one dollar need not be paid. You or Your assignee Covered Trip;
shall be notified by the Company or designated representative of any known d) Strike that causes complete cessation of services for at least
failure to provide sufficient documentation for a due proof of loss within 30 twenty-four (24) consecutive hours;
days after receipt of the claim. Any required interest payments shall be
e) Weather that causes complete cessation of services for at least
made within 30 days after the payment.
twenty-four (24) consecutive hours and prevents You from reaching
The following provisions apply to Baggage/Personal Effects and Baggage Your destination;
Delay coverages: f) Bankruptcy and/or Default of Your Travel Supplier that occurs more
NOTICE OF LOSS – If Your property covered under the Group Policy is lost, than 14 days following Your Effective Date. Coverage is not provided
stolen or damaged, You must: for the Bankruptcy or Default of the agency from whom You purchased
(a) notify the Company, or its authorized representative as soon as possible; Your Land/Sea Arrangements. Your Scheduled Departure Date must
be no more than 15 months beyond Your Effective Date. Benefits will
(b) take immediate steps to protect, save and/or recover the covered be paid due to Bankruptcy or Default of an airline only if no alternate
property; transportation is available. If alternate transportation is available,
(c) give immediate notice to the carrier or bailee who is or may be liable benefits will be limited to the change fee charged to allow You to
for the loss or damage; transfer to another airline in order to get to Your intended destination;
(d) notify the police or other authority in the case of robbery or theft within g) Natural disaster at the site of Your destination that renders Your
twenty-four (24) hours. destination accommodations Uninhabitable;
h) You or a Traveling Companion is called into active military service to
PROOF OF LOSS – You must furnish the Company, or its designated
provide aid or relief in the event of a natural disaster;
representative, with proof of loss. This must be a detailed sworn statement.
It must be filed with the Company, or its designated representative within i) You or Your Traveling Companion being required to work during the
ninety (90) days from the date of loss. Failure to comply with these Trip. Proof of requirement to work, such as notarized statement signed
conditions shall invalidate any claims under the Group Policy. by an officer of the You or Your Traveling Companion’s employer must
be presented and said employer must comprise of at least 25 full-time
SETTLEMENT OF LOSS – Claims for damage and/or destruction shall be employees;
paid after acceptable proof of the damage and/or destruction is presented
to the Company and the Company has determined the claim is covered. j) You or Your Traveling Companion’s company being made unsuitable
Claims for lost property will be paid after the lapse of a reasonable time if for business by fire, flood, burglary, vandalism or other natural disaster
the property has not been recovered. You must present acceptable proof of and You or Your Traveling Companion is responsible for policy and
loss and the value involved to the Company. decision making with the company and is directly involved as a
member of the disaster recovery team;
VALUATION - The Company will not pay more than the actual cash value
k) You or Your Traveling Companion’s company being indirectly involved
of the property at the time of loss. Damage will be estimated according to
in a merger, acquisition, government required product recall or
actual cash value with proper deduction for depreciation as determined by
bankruptcy proceedings. You or Your Traveling Companion must be
the Company. At no time will payment exceed what it would cost to repair
an active employee of the company and must be directly involved in
or replace the property with material of like kind and quality.
said event;
DISAGREEMENT OVER SIZE OF LOSS: If there is a disagreement about the l) You or Your Traveling Companion has a previously approved military
amount of the loss either You or the Company can make a written demand leave revoked or experience a military re-assignment.
for an appraisal. After the demand, You and the Company will each select
Your own competent appraiser. After examining the facts, each of the two The Company will reimburse You for the following:
appraisers will give an opinion on the amount of the loss. If they do not agree, a) non-refundable cancellation charges imposed by the Participating
they will select an arbitrator. Any figure agreed to by 2 of the 3 (the appraisers Organization and/or Travel Suppliers.
and the arbitrator) will be binding. The appraiser selected by You is paid by In no event shall the amount reimbursed exceed the amount You prepaid
You. The Company will pay the appraiser they choose. You will share equally for the Covered Trip.
with the Company the cost for the arbitrator and the appraisal process.
You must provide the following documentation when presenting a claim
BENEFITS for these benefits:
a) Written confirmation of the reasons for delay from the Common Carrier
TRIP CANCELLATION whose delay resulted in the Loss, including but not limited to, scheduled
The Company will pay a benefit, up to the Maximum Benefit shown on the departure and return times and actual departure and return times.
Schedule, if You are prevented from taking Your Covered Trip for any of the SPECIAL CONDITIONS: You must advise the Participating Organization and
following reasons that take place after the Effective Date: the Company within 72 hours in the event of a claim. If the claim is not
a) Sickness, Accidental Injury or death of You, Traveling Companion, reported within 72 hours, it should be reported as soon as possible. All
or Family Member which results in medically imposed restrictions as other delays of reporting beyond 72 hours will result in reduced benefit
certified by a Physician at the time of loss preventing your continued payments. The Company will not pay benefits for any additional charges
participation in the Trip. A Physician must advise cancellation of the incurred that would not have been charged had You notified the Participating
Trip on or before the Scheduled Departure Date; Organization as soon as reasonably possible.
b) You or a Traveling Companion being hijacked, quarantined, required SINGLE OCCUPANCY COVERAGE: The Company will reimburse You, up to
to serve on a jury, subpoenaed, the victim of felonious assault within the maximum shown on the Confirmation of Coverage, for the additional
10 days of departure; or having Your principal place of residence made cost incurred during the Covered Trip as a result of a change in the per
uninhabitable by fire, flood or other natural disaster; or burglary of Your person occupancy rate for prepaid travel arrangements if a person booked
principal place of residence within 10 days of departure; to share accommodations with You has Your Trip delayed, canceled or
interrupted for a covered reason and You do not cancel.
SRTC 2500 VA -4-
 TRIP INTERRUPTION The Company will pay for reasonable additional accommodation and
transportation expenses incurred by You (up to $250 a day) if a Traveling
The Company will pay a benefit, up to the maximum shown on the Companion must remain hospitalized or if You must extend the Trip with
Confirmation of Coverage, if You are unable to continue on Your Covered additional hotel nights due to a Physician certifying that You cannot fly
Trip due to: home due to an Accident or Sickness but does not require hospitalization.
a) Sickness, Accidental Injury or death of You, Traveling Companion,
or Family Member which results in medically imposed restrictions as In no event shall the amount reimbursed exceed the amount You prepaid
certified by a Physician at the time of loss preventing Your continued for the Covered Trip.
participation in the Trip; TRIP DELAY
b) You or a Traveling Companion being hijacked, quarantined, required The Company will reimburse You for Covered Expenses on a one-time
to serve on a jury, subpoenaed, the victim of felonious assault within basis, up to the maximum shown in the Confirmation of Coverage, if You
10 days of departure; or having Your principal place of residence made are delayed en route to or from the Covered Trip for six (6) or more hours
uninhabitable by fire, flood or other natural disaster; or burglary of Your due to a defined Hazard:
principal place of residence within 10 days of departure;
Covered Expenses include:
c) A Terrorist Attack (or Attacks) occurs in Your departure city or in a city
a) Any prepaid, nonrefundable land and water accommodations; or
that is still a scheduled destination for Your Covered Trip, provided:
the Terrorist Attack (or Attacks) occurs within thirty (30) days of b) Any reasonable additional expenses incurred.
the scheduled departure date for Your Covered Trip or during Your ACCIDENTAL DEATH AND DISMEMBERMENT
Covered Trip;
The Company will pay the percentage of the Principal Sum shown in the
d) Strike that causes complete cessation of services for at least Table of Losses when You, as a result of an Accidental Injury occurring
twenty-four (24) consecutive hours; during the Covered Trip, sustain a loss shown in the Table below. The
e) Weather that causes complete cessation of services for at least loss must occur within 180 days after the date of the Accident causing the
twenty-four (24) consecutive hours and prevents You from reaching loss. The Principal Sum is shown on the Confirmation of Coverage. The
Your destination; maximum benefits for any one single Accident is limited to $15,000,000
f) Bankruptcy and/or Default of Your Travel Supplier that occurs more for all persons insured under the Group Policy. If more than one loss is
than 14 days following Your Effective Date. Coverage is not provided sustained, as the result of an Accident, the amount payable shall be the
for the Bankruptcy or Default of the agency from whom You purchased largest amount of a sustained loss shown in the Table of Losses.
Your Land/Sea Arrangements. Your Scheduled Departure Date must TABLE OF LOSSES
be no more than 15 months beyond Your Effective Date. Benefits will LOSS OF: PERCENTAGE OF PRINCIPAL SUM:
be paid due to Bankruptcy or Default of an airline only if no alternate
transportation is available. If alternate transportation is available, Loss of Life...........................................................................................100%
benefits will be limited to the change fee charged to allow You to Loss of both hands...............................................................................100%
transfer to another airline in order to get to Your intended destination; Loss of both feet...................................................................................100%
Loss of both eyes.................................................................................100%
g) Natural disaster at the site of Your destination that renders the
Loss of one hand and one foot.............................................................100%
destination accommodations Uninhabitable;
Loss of one hand and one eye.............................................................100%
h) You or a Traveling Companion is called into active military service to Loss of one foot and one eye...............................................................100%
provide aid or relief in the event of a natural disaster; Loss of one hand....................................................................................50%
i) You or Your Traveling Companion being required to work during Loss of one foot......................................................................................50%
the Covered Trip. Proof of requirement to work, such as notarized Loss of Sight of one eye.........................................................................50%
statement signed by an officer of the You or Your Traveling Companion’s Loss of Speech and hearing in both ears.............................................100%
employer must be presented and said employer must comprise of at Loss of Speech.......................................................................................50%
least 25 full-time employees; Loss of Hearing in both ears...................................................................50%
j) You or Your Traveling Companion’s company being made unsuitable Loss of Thumb and index finger of same hand......................................25%
for business by fire, flood, burglary, vandalism or other natural disaster “Loss” with regard to:
and You or Your Traveling Companion is responsible for policy and 1. hand or foot, means actual complete severance through and above
decision making with the company and is directly involved as a the wrist or ankle joints;
member of the disaster recovery team; 2. eye means an entire and irrecoverable loss of sight;
k) You or Your Traveling Companion’s company being indirectly involved 3. speech or hearing means entire and irrecoverable loss of speech or
in a merger, acquisition, government required product recall or hearing of both ears; and
bankruptcy proceedings. You or Your Traveling Companion must be 4. thumb and index finger means actual severance through or above the
an active employee of the company and must be directly involved in joint that meets the finger at the palm.
said event;
EXPOSURE
l) You or Your Traveling Companion has a previously approved military The Company will pay benefits for covered losses that result from You
leave revoked or experience a military re-assignment. being unavoidably exposed to the elements due to an Accident. The loss
The Company will reimburse You for the following: must occur within 365 days after the event that caused the exposure.
a) unused, non-refundable land or sea expenses prepaid to the DISAPPEARANCE
Participating Organizations and/or Travel Suppliers; The Company will pay benefits for loss of life if Your body cannot be located
b) the airfare paid less the value of applied credit from an unused travel one year after Your disappearance due to an Accident.
ticket, to return home, join or rejoin the original Land/Sea Arrangements EMERGENCY ACCIDENT MEDICAL EXPENSE
limited to the cost of one-way economy airfare by scheduled carrier,
The Company will pay benefits up to the maximum shown on the Confirmation
from the point of destination to the point of origin shown on the original
of Coverage, if You incur Covered Medical Expenses for Emergency
travel tickets.
Treatment of an Accidental Injury that occurs during the Covered Trip.

SRTC 2500 VA -5-

Emergency Treatment means necessary medical treatment, including EXCESS INSURANCE LIMITATION
services and supplies, which must be performed during the Covered Trip due The insurance provided by the Group Policy shall be in excess of all other
to the serious and acute nature of the Accidental Injury. valid and collectible insurance or indemnity. If at the time of the occurrence of
Covered Medical Expenses are necessary services and supplies that are any loss there is other valid and collectible insurance or indemnity in place,
recommended by the attending Physician. They include, but are not limited to: the Company shall be liable only for the excess of the amount of loss, over
the amount of such other insurance or indemnity, and applicable deductible.
a) the services of a Physician;
b) charges for Hospital confinement and use of operating rooms;
EMERGENCY EVACUATION
c) charges for anesthetics (including administration); x- ray examinations The Company will pay benefits for Covered Expenses incurred, up to the
or treatments, and laboratory tests; maximum shown on the Confirmation of Coverage, if an Accidental Injury
or Sickness commencing during the course of the Covered Trip results in
d) ambulance service; and Your necessary Emergency Evacuation. An Emergency Evacuation must be
e) drugs, medicines, prosthetic and therapeutic services and supplies. ordered by a Physician who certifies that the severity of Your Accidental Injury
The Company will not pay benefits in excess of the reasonable and customary or Sickness warrants the Your Emergency Evacuation.
charges. Reasonable and customary charges means charges commonly Emergency Evacuation means:
used by Physicians in the locality in which care is furnished. The Company (a) Your medical condition warrants immediate transportation from the
will not cover any expenses provided by another party at no cost to You or place where You are injured or sick to the Hospital of Your choice
already included within the cost of the Trip. where appropriate medical treatment can be obtained;
The Company will pay benefits, up to $750.00, for emergency dental treatment (b) after being treated at a local Hospital, Your medical condition warrants
for Accidental Injury to sound natural teeth. transportation to the United States where You reside, to obtain further
The Company will advance payment to a Hospital, up to the maximum medical treatment or to recover; or
shown on the Confirmation of Coverage, if needed to secure Your admission (c) both (a) and (b), above.
to a Hospital because of Accidental injury.
Covered Expenses are reasonable and customary expenses for necessary
If You are hospitalized due to an Accidental Injury which first occurred during transportation, related medical services and medical supplies incurred in
the course of the scheduled Trip beyond the date of the Scheduled Return connection with Your Emergency Evacuation. All transportation arrangements
Date, coverage will be extended until You are released from the Hospital or made for evacuating You must be by the most direct and economical route
until maximum benefits under the Group Policy have been paid. possible. Expenses for transportation must be:
EXCESS INSURANCE LIMITATION (a) recommended by the attending Physician;
The insurance provided by the Group Policy shall be in excess of all other (b) required by the standard regulations of the conveyance transporting
valid and collectible insurance or indemnity. If at the time of the occurrence of You; and
any loss there is other valid and collectible insurance or indemnity in place,
(c) authorized in advance by the Company or its authorized representative.
the Company shall be liable only for the excess of the amount of loss, over
the amount of such other insurance or indemnity, and applicable deductible. Transportation of Dependent Children: If You are in the Hospital for more
than seven (7) days, the Company will return Your dependents, who are
EMERGENCY SICKNESS MEDICAL EXPENSE under 18 years of age and accompanying You on the scheduled Trip, to their
The Company will pay benefits up to the maximum shown on the home, with an attendant if necessary.
Confirmation of Coverage, if You incur Covered Medical Expenses as a
Transportation to Join You: If You are traveling alone and are in a Hospital
result of Emergency Treatment of a Sickness that first manifests itself
alone for more than seven (7) consecutive days or if the attending Physician
during the Covered Trip.
certifies that due to Your Injury or Sickness, You will be required to stay in
Emergency Treatment means necessary medical treatment, including the Hospital for more than seven (7) consecutive days, upon request the
services and supplies, which must be performed during the Covered Trip Company will bring a person, chosen by You, for a single visit to and from
due to the serious and acute nature of the Sickness. Your bedside provided that repatriation is not imminent.
Covered Medical Expenses are necessary services and supplies that are Transportation services are provided if authorized in advance by the
recommended by the attending Physician. They include but are not limited to: assistance provider, and are limited to necessary economy fares less the
a) the services of a Physician; value of applied credit from unused travel tickets, if applicable.
b) charges for Hospital confinement and use of operating rooms; Transportation means any Common Carrier, or other land, water or air
c) charge for anesthetics (including administration); x-ray examinations conveyance, required for an Emergency Evacuation and includes air
or treatments, and laboratory tests; ambulances, land ambulances and private motor vehicles.
d) ambulance service; and The Company will not cover any expenses provided by another party at no
cost to You or already included within the cost of the Covered Trip.
e) drugs, medicines, prosthetics and therapeutic services and supplies.
EXCESS INSURANCE LIMITATION
The Company will not pay benefits in excess of the reasonable and
The insurance provided by the Group shall be in excess of all other valid
customary charges. Reasonable and customary charges mean charges
and collectible insurance or indemnity. If at the time of the occurrence of any
commonly used by Physicians in the locality in which care is furnished. The
loss there is other valid and collectible insurance or indemnity in place, the
Company will not cover any expenses provided by another party at no cost
Company shall be liable only for the excess of the amount of loss, over the
to You or already included within the cost of the Trip.
amount of such other insurance or indemnity, and applicable deductible.
The Company will advance payment to a Hospital, up to the maximum
Hospital of Choice: You may choose a non-emergency medical
shown on the Confirmation of Coverage, if needed to secure Your admission
evacuation to a Hospital in a city within the U.S. or Canada other than
to a Hospital because of Sickness.
Your city of residence, but the maximum amount payable is limited to the
If You are hospitalized due to a Sickness which first occurred during the cost of a medical evacuation to Your home city of residence.
course of the scheduled Trip beyond the date of the Scheduled Return
Date, coverage will be extended until You are released from the Hospital or
until maximum benefits under the Group Policy have been paid.

SRTC 2500 VA -6-

 REPATRIATION OF REMAINS 8. being under the influence of drugs or intoxicants, unless prescribed by
The Company will pay the reasonable Covered Expenses incurred to return a Physician unless results in the death of a non-traveling immediate
Your body to Your primary place of residence if You die during the Trip. This Family Member;
will not exceed the maximum shown on the Confirmation of Coverage. 9. commission or the attempt to commit a criminal act;
Covered Expenses include, but are not limited to, expenses for embalming, 10. dental treatment except as a result of an injury to sound natural teeth
cremation, casket for transport and transportation. within twelve (12) months of the Accidental Injury;
BAGGAGE/PERSONAL EFFECTS 11. any non-emergency treatment or surgery, routine physical examinations,
hearing aids, eye glasses or contact lenses;
The Company will reimburse You, up to the maximum shown on the
Schedule, for loss, theft or damage to baggage and personal effects, 12. pregnancy and childbirth (except for complications of pregnancy)
including, but not limited to sporting equipment, provided You have taken except if hospitalized;
all reasonable measures to protect, save and/or recover Your property 13. traveling for the purpose of securing medical treatment;
at all times. The baggage and personal effects must be owned by and 14. directly or indirectly, the actual, alleged or threatened discharge,
accompany You during the Covered Trip. dispersal, seepage, migration, escape, release or exposure to any
This coverage is secondary to any coverage provided by a Common Carrier hazardous biological, chemical, nuclear radioactive material, gas,
and all other valid and collectible insurance indemnity and shall apply only matter or contamination;
when such other benefits are exhausted. 15. care or treatment that is payable under any Insurance policy that does
There will be a per article limit shown on the Confirmation of Coverage. not require deductible and/or coinsurance payments by You;
There will be a combined maximum limit shown on the Confirmation of 16. Care or treatment that is not medically necessary;
Coverage for the following: jewelry; watches; articles consisting in whole 17. Care or treatment for which compensation is payable under Worker’s
or in part of silver, gold or platinum; furs; articles trimmed with or Compensation Law, any Occupational Disease law; the 4800 Time
made mostly of fur. Benefit plan or similar legislation;
The Company will pay the lesser of the following: 18. Injury or Sickness when traveling against the advice of a Physician.
(a) Actual Cash Value at time of loss, theft or damage to baggage and The following exclusions apply to Baggage/Personal Effects and
personal effects, less depreciation as determined by the Company; or Baggage Delay:
(b) the cost of repair or replacement. The Company will not provide benefits for any loss or damage to:
EXTENSION OF COVERAGE: If You checked Your property with a Common 1. animals;
Carrier and delivery is delayed, coverage for Baggage/Personal Effects will 2. automobiles and automobile equipment;
be extended until the Common Carrier delivers the property. 3. boats or other vehicles or conveyances;
BAGGAGE DELAY 4. trailers;
The Company will reimburse You for the expense of necessary personal 5. motors;
effects, up to the maximum shown on the Confirmation of Coverage, if Your 6. motorcycles;
Checked Baggage is delayed or misdirected by a Common Carrier for more
than twelve (12) hours, while on a Covered Trip. 7. aircraft;
8. bicycles (except when checked as baggage with a Common Carrier);
You must be a ticketed passenger on a Common Carrier.
9. household effects and furnishing;
Additionally, all claims must be verified by the Common Carrier who must
certify the delay or misdirection and receipts for the purchases must 10. antiques and collector’s items;
accompany any claim. 11. eye glasses, sunglasses or contact lenses;
12. artificial teeth and dental bridges;
LIMITATIONS AND EXCLUSIONS 13. hearing aids;
14. prosthetic limbs;
The following exclusions apply to Trip Cancellation, Trip Interruption, 15. prescribed medications;
Trip Delay, Accidental Death & Dismemberment, Emergency Accident
Medical Expense, Emergency Sickness Medical Expense, Emergency 16. keys, money, stamps and securities;
Evacuation, and Repatriation of Remains: 17. tickets;
Loss caused by or resulting from: 18. credit cards;
1. Pre-Existing Conditions, as defined in the Definitions section (except 19. professional or occupational equipment or property, whether or not
Emergency Evacuation and Repatriation of Remains); electronic business equipment;
20. sporting equipment if loss or damage results from the use thereof.
2. suicide, attempted suicide or any intentionally self-inflicted injury while
sane or insane (in Missouri, sane only) unless results in the death of Any loss caused by or resulting from the following is excluded:
a non-traveling immediate Family Member; 1. breakage of brittle or fragile articles;
3. war, invasion, acts of foreign enemies, hostilities between nations 2. wear and tear or gradual deterioration;
(whether declared or not), civil war; 3. insects or vermin;
4. participation in any military maneuver or training exercise; 4. inherent vice or damage while the article is actually being worked upon
5. piloting or learning to pilot or acting as a member of the crew of or processed;
any aircraft; 5. confiscation or expropriation by order of any government;
6. mental or emotional disorders, unless hospitalized; 6. war or any act of war whether declared or not;
7. participation as a professional in athletics; 7. theft or pilferage while left unattended in any vehicle;
8. mysterious disappearance;
SRTC 2500 VA -7-
9. property illegally acquired, kept, stored or transported; The difference between the cost of a private hospital room and a semi-
10. insurrection or rebellion; private hospital room is not considered an Allowable Expense under
the above definition unless the patient’s stay in a private hospital room is
11. imprudent action or omission; medically necessary in terms of generally accepted medical practice.
12. property shipped as freight or shipped prior to the Scheduled
Departure Date. When a Plan provides benefits in the form of services, the reasonable cash
value of each service will be considered both an Allowable Expense and a
benefit paid.
COORDINATION OF BENEFITS Claim is a request that benefits of a Plan be provided or paid. The benefits
claimed may be in the form of:
Applicability
(a) services (including supplies);
The Coordination of Benefits (“COB”) provision applies to This Plan when
(b) payment for all or a portion of the expenses incurred; or
You have health care coverage under more than one Plan. “Plan” and “This
Plan” are defined below. (c) a combination of (a) and (b).
If this COB provision applies, the order of benefit determination rules should Claim Determination Period is the period of time, which must not be less
be looked at first. than 12 consecutive months, over which Allowable Expenses are compared
with total benefits payable in the absence of COB, to determine:
Those rules determine whether the benefits of This Plan are determined
before or after those of another Plan. (a) whether other insurance exists; and
(b) how much each Plan will pay or provide.
The benefits of This Plan:
(a) will not be reduced when, under the order of benefit determination For the purposes of this contract, Claim Determination Period is the
rules, This Plan determines its benefits before another Plan; but period of time beginning with the effective date of coverage and ending
12 consecutive months following the date of loss or longer as may be
(b) may be reduced when, under the order of benefit determination rules, determined by the proof of loss provision.
another Plan determines its benefits first. This reduction is described
further in the section entitled Effect on the Benefits of This Plan. Order of Benefit Determination Rules
Definitions When This Plan is a Primary Plan, its benefits are determined before those
of any other Plan and without considering another Plan’s benefits.
Plan is a form of written on an expense incurred basis that provides benefits
or services for, or because of, medical or dental care or treatment. “Plan” When This Plan is a Secondary Plan, its benefits are determined after
includes: those of any other Plan only when, under these rules, it is secondary to
that other Plan.
(a) group insurance and group remittance subscriber contracts;
(b) uninsured arrangements of group coverage; When there is a basis for a Claim under This Plan and another Plan, This
Plan is a Secondary Plan that has its benefits determined after those of the
(c) group coverage through HMO’s and other prepayment, group practice other Plan, unless:
and individual practice Plans; and
(a) the other Plan has rules coordinating its benefits with those of This
(d) blanket contracts, except blanket school accident coverages or a Plan; and
similar group when the Policyholder pays the premium.
(b) both those rules and This Plan’s rules, as described below, require that
“Plan” does not include individual or family: This Plan’s benefits be determined before those of the other Plan.
(a) insurance contracts; Rules
(b) direct payment subscriber contracts;
This Plan determines its order of benefits using the first of the following
(c) coverage through HMO’s; or (d) coverage under other prepayment, rules which applies:
group practice and individual practice Plans.
(a) Nondependent/Dependent Rule. The benefits of the Plan that covers
This Plan is the parts of this blanket contract that provide benefits for health the person as an employee, member or subscriber (that is, other than
care expenses on an expense incurred basis. as a dependent) are determined before those of the Plan that covers
Primary Plan is one whose benefits for a person’s health care coverage the person as a dependent.
must be determined without taking the existence of any other Plan into (b) Longer/Shorter Length of Coverage Rule. The benefits of the Plan that
consideration. A Plan is a Primary Plan if either: covered an employee, member or subscriber longer are determined
(a) the Plan either has no order of benefit determination rules, or it has before those of the Plan that covered that person for the shorter time.
rules that differ from those in the contract; or To determine the length of time a person has been covered under a Plan,
(b) all Plans that cover the person use the same order of benefits two Plans shall be treated as one if the claimant was eligible under the
determination rules as in this contract, and under those rules the Plan second within 24 hours after the first ended. Thus, the start of a new Plan
determines its benefits first. does not include: (a) a change in the amount or scope of a Plan’s benefits;
(b) a change in the entity which pays, provides or administers the Plan’s
Secondary Plan is one that is not a Primary Plan. If a person is covered benefits; or (c) a change from one type of Plan to another. The claimant’s
by more than one Secondary Plan, the order of benefit determination rules length of time covered under a Plan is measured from the claimant’s first
of this contract decide the order in which their benefits are determined in date of coverage under that Plan. If that date is not readily available, the
relation to each other. The benefits of each Secondary Plan may take into date the claimant first became a member of the group shall be used as the
consideration the benefits of the Primary Plan or Plans and the benefits date from which to determine the length of time the claimant’s coverage
of any other Plan which, under the rules of this contract, has its benefits under the present Plan has been in force.
determined before those of that Secondary Plan.
Allowable Expense is the necessary, reasonable, and customary item of
expense for health care; when the item of expense is covered at least in
part under any of the Plans involved.

SRTC 2500 VA -8-

Effect on the Benefits of This Plan When it is Secondary
The benefits of This Plan will be reduced when it is a Secondary Plan
so that the total benefits paid or provided by all Plans during a Claim
Determination Period are not more than the total Allowable Expenses, not
otherwise paid, which were incurred during the Claim Determination Period
by the person for whom the Claim is made. As each Claim is submitted,
This Plan determines its obligation to pay for Allowable Expenses based
on all Claims that were submitted up to that point in time during the Claim
Determination Period.
Right to Receive and Release Needed Information
Certain facts are needed to apply these COB rules. The Company has the
right to decide which facts are needed. The Company may get needed facts
from or give them to any other organization or person. The Company need
not tell, or get the consent of, any person to do this. Each person claiming
benefits under This Plan must give the Company any facts we need to pay
the Claim.
Facility of Payment
A payment made under another Plan may include an amount that should
have been paid under This Plan. If it does, the Company may pay that
amount to the organization that made that payment. That amount will then
be treated as though it were a benefit paid under This Plan. The Company
will not have to pay that amount again. The term “payment made” includes
providing benefits in the form of services, in which case “payment made”
means reasonable monetary value of the benefits provided in the form of
services.
Right of Recovery
If the amount of the payments made by the Company is more than the
Company should have paid under this COB provision, the Company may
recover the excess from one or more of: (a) the persons we have paid or for
whom we have paid; (b) insurance companies; or (c) other organizations.
Non-complying Plans
This Plan may coordinate its benefits with a Plan that is excess or always
secondary or which uses order of benefit determination rules which are
inconsistent with those of This Plan (non-complying Plan) on the following
basis:
(a) If This Plan is the Primary Plan, This Plan will pay its benefits on a
primary basis;
(b) if This Plan is the Secondary Plan, This Plan will pay its benefits first,
but the amount of the benefits payable will be determined as if This
Plan were the Secondary Plan. In this situation, our payment will be
the limit of This Plan’s liability; and
(c) if the non-complying Plan does not provide the information needed
by This Plan to determine its benefits within 30 days after it is
requested to do so, the Company will assume that the benefits of the
non-complying Plan are identical to This Plan and will pay benefits
accordingly. However, the Company will adjust any payments made
based on this assumption whenever information becomes available
as to the actual benefits of the non-complying Plan.

SRTC 2500 VA -9-

 VIRGINIA AMENDMENT RIDER

The certificate to which this rider is attached is amended as follows:

Under the section entitled “General Provisions” the following changes are made:

The provision entitled “Subrogation” is amended to read:

SUBROGATION - To the extent the Company pays for a loss suffered by You, the Company
will take over the rights and remedies You had relating to the loss. This is known as
subrogation. You must help the Company to preserve its rights against those responsible for the
loss. This may involve signing any papers and taking any other steps the Company may
reasonably require. If the Company takes over Your rights, You must sign an appropriate
subrogation form supplied by the Company. (This provision does not apply to the Sickness
Medical Expense, Emergency Sickness Medical Expense, Accident Medical Expense,
Emergency Medical Expense, and Emergency Accident Medical Expense Benefits.)

There are no other changes to the certificate.

Signed for Nationwide Mutual Insurance Company

Joe San Filippo

Vice President, Ohio Health Operations
Nationwide Mutual Insurance Company

Form SRTC 2200-VA

 Non-Insurance Services One Call Concierge Services
One Call 24-Hour Assistance Services • Restaurant, shopping, hotel recommendations/reservations
Global Xpi Medical Records Service • Local transport (rental car/limousine, etc.) information and reservations
• Sporting, theatre, night life and event information (sports scores, stock
quotes, gift suggestions, etc.), recommendations and ticketing
• Golf course information, referrals, recommendations and tee times
One Call • Tracking and assisting with the return of lost or delayed baggage
Worldwide Travel Services Network
One Call Business Services
Medical Assistance - Our multi-lingual professionals are available 24 hours • emergency correspondence and business communication assistance
a day to provide help, advice and referrals for medical emergencies. We will • assistance with locating available business services such as: express/
help you locate local physicians, dentists, or medical facilities. overnight delivery sites, internet cafes, print/copy services
Medical Consultation and Monitoring - If you are hospitalized, we will contact • assistance with or arrangements for telephone and web conferencing
you and your treating physician to monitor your condition to assure you are • emergency messaging to customers, associates, and others (phone,
receiving appropriate care and assess the need for further assistance. We fax, e-mail, text, etc.)
will also contact your personal physician and family at home when necessary • real time weather, travel delay and flight status information
or requested to keep them informed of your situation.
• worldwide business directory service for equipment repair/replacement,
Medical Evacuation - When medically necessary, we will arrange and pay for warranty service, etc.
appropriate transportation, including an escort, if required, to a suitable hospital, • emergency travel arrangements
treatment facility or home. Payment for Medical Evacuation is available only for
covered claims and up to the amount of coverage provided in the policy. All One Call Travel Solutions
medical transportation services must be authorized and arranged by One Call. 24-Hour Worldwide Travel Services
In the event of an unauthorized Medical Evacuation, reimbursement may be
limited or coverage may be invalidated. Message Services - We will transmit emergency messages to family, friends
or business associates and let you know that the message has been received.
Emergency Medical Payments - We will assist you in the advancement of
funds or guarantee payments (up to the policy limits) to a hospital or other Language Interpretation Services - We provide interpretation services in
medical provider, if required, to secure your admission, treatment or discharge. major languages and will refer you to appropriate local services, if needed.

Prescription Assistance - We will assist you with replacing medications that Emergency Cash Transfer - We will help arrange an emergency cash
are lost, stolen or spoiled during your Trip, either locally or by special courier. transfer (wire transfer, travelers checks, etc.) of your funds from home or from
friends or family in medical or travel emergency situations where additional
Repatriation of Remains - In the event of death while on a Trip, we will funds are required.
arrange for the preparation and transportation required to return your remains
Pre-Trip Travel Services - We provide 24-Hour information, help and
to your home.
advice for your planned Trip such as: passport and visa information,
24 Hour Legal Assistance - If while on your Trip you encounter legal requirements and replacement; travel health information or advisories;
vaccine recommendations and requirements; government agency contact
problems, we will help you find a local legal advisor. If you are required to
information (i.e. embassies, consulates, and other departments or agencies);
post bail or provide immediate payment of legal fees, we will assist you in weather and currency information.
arranging a funds transfer from family or friends.
Travel Document and Ticket Replacement - When important travel
Nurse Helpline - Registered nurses are available 24-Hours a day before and documents (such as passports and visas) are lost or stolen, we will help
during your Trip to provide general health information, clinical assessment, you to secure replacements. We will also help you when airline or other
and health counseling to give you assistance in making appropriate travel tickets are lost or stolen. We will assist you with reporting your loss,
healthcare decisions. reissuing tickets and obtaining the money required for this purpose (you are
responsible for providing the funds).
CONTACTING ONE CALL’S 24-HOUR SERVICE CENTER ACCESS YOUR MEDICAL RECORDS ONLINE

When outside the USA or Canada, call us collect through a local operator With Global Xpi, you can relax knowing your important medical records are
(you will first have to enter the International Access Code of the country available to you or any Physician chosen by you, at anytime, anywhere in
you are calling from). Within the USA or Canada, use the toll free number. the world, wherever internet access is available.
Within U.S.A. & Canada Outside U.S.A. & Canada Register at www.globalxpi.com or call, toll free:
1-855-878-9588 1-603-328-1329 1-800-379-9887 Use Program Code N300S
YOUR PLAN NUMBER: N300S These Services are Provided by: Global Xpi, a Trip Mate brand.

The 24-Hour Assistance Services are provided by One Call Worldwide Travel Services Network. While we strive to provide help and advice for problems
encountered by travelers wherever or whenever they occur, situations may arise beyond our control when immediate resolution is not possible. We will make every
reasonable effort to refer you to appropriate medical and legal providers, but neither the Insurer nor One Call Worldwide Travel Services Network may be held
responsible for the availability, quality or results of any medical treatment or your failure to obtain medical treatment.
 What we do
To protect your personal information from unauthorized
How does access and use, we use security measures that comply with
Nationwide Protect federal and state law. These measures include computer
my personal safeguards and secured files and buildings. We limit access
information? to your information to those who need it to do their job.
We collect your personal information, for example, when
How does you:
Rev. 5/2017 Nationwide collect • Apply for insurance
• Make a payment or file a claim
my personal • Conduct business with us
information? We also collect your personal information from others,
WHAT DOES NATIONWIDE DO WITH YOUR PERSONAL
FACTS such as credit bureaus, affiliates, or other companies.
INFORMATION?
Financial companies choose how they share your personal Federal and state law gives you the right to limit only:
information. Federal and state law gives consumers the right to • Sharing for affiliates’ everyday business purposes
limit some but not all sharing. Federal and state law also requires information about your creditworthiness;
Why? us to tell you how we collect, share, and protect your personal Why can’t I limit all • Affiliates from using your information to market to you;
information. Please read this notice carefully to understand what sharing? and
we do. • Sharing for nonaffiliates to market to you.
The types of personal information we collect and share depend State laws and individual companies may give you additional
on the product or service you have with us. This information can rights to limit sharing. See below for more information.
include: What happens
• Social Security number, government issued identification, and
What? when I limit sharing
contact information
• Policy, account, and contract information and contact for an account I Your choices will apply to everyone on your account.
information hold jointly with
• Credit reports and other consumer reports someone else?

All financial companies need to share customers’ personal Definitions

information to run their everyday business. In the section below, Companies related by common ownership or control.
How? we list the reasons financial companies can share their customers’ They can be financial and nonfinancial companies. These
personal information; the reasons Nationwide chooses to share; companies include Nationwide Life Insurance Company,
and whether you can limit this sharing. Affiliates Nationwide Bank, and Nationwide Property and Casualty
Insurance Company. Visit nationwide.com for a list of
affiliated companies.
Does Can you
Reasons we can share your Companies not related by common ownership or control.
Nationwide limit this Nonaffiliates
personal information They can be financial and nonfinancial companies.
share? sharing?
For our everyday business purposes— A formal agreement between nonaffiliated financial
such as to process your transactions, Joint marketing companies that together market financial products or
maintain your account(s), respond to court Yes No services to you.
orders and legal investigations, or report to
credit bureaus Other important information

For our marketing purposes— to offer California Residents: We currently do not share information we collect about you
Yes No with affiliated or nonaffiliated companies for their marketing purposes. Therefore,
our products and services to you
you do not need to opt out.
For joint marketing with other financial Yes No Nevada Residents: You may request to be placed on our internal Do Not Call
companies
list. Send an email with your phone number to privacy@nationwide.com. You
For our affiliates’ everyday business may request a copy of our telemarketing practices. For more on this Nevada law,
purposes— information about your Yes No contact Bureau of Consumer Protection, Office of the Nevada Attorney General,
transactions and experiences 555 E. Washington St., Suite 3900, Las Vegas, NV 89101; Phone number:
1-702-486-3132; email: BCPINFO@ag.state.nv.us.
For our affiliates’ everyday business
purposes— information about your Yes Yes Vermont Residents: For Vermont customers only. We will not share your personal
creditworthiness information for marketing purposes with the Nationwide family of companies or
third parties without your authorization, except as permitted by law.
For our affiliates to market to you Yes Yes
AZ, CA, CT, GA, IL, ME, MA, MT, NV, NJ, NM, NC, ND, OH, OR, and VA
For our nonaffiliates to market to you Yes Yes Residents: The Term “Information” means information we collect during an insurance
transaction. We will not use your medical information for marketing purposes without
• Call us toll free at 1-866-280-1809 and our menu will your consent. We may share information with others, including insurance regulatory
prompt you through your choices authorities, law enforcement, consumer reporting agencies, and insurance-support
• If you have previously opted out, your preference remains organizations without your prior authorization as permitted or required by law.
on file and you do not need to opt out again. Information we obtain from a report prepared by an insurance-support organization
To limit our • Please have your account or policy number handy when
sharing may be retained by that insurance-support organization and disclosed to others.
you call.
Please note: If you are a new customer, we can begin Accessing your information
sharing your information 30 days from the date we sent You can ask us for a copy of your personal information. Please send your request
this notice. When you are no longer our customer, we to the address below and have your signature notarized. This is for your protection
continue to share your information as described in this so we may prove your identity. Please include your name, address, and policy
notice. However, you can contact us at any time to limit number. You can change your personal information at Nationwide.com or by
our sharing. calling your agent. We can’t change information that other companies, like credit
agencies, provide to us. You’ll need to ask them to change it.
Questions? 1-844-207-1930
Trip Mate, Inc.
Who we are Attn: Privacy Officer
Who is providing 9225 Ward Parkway, Suite 200
Nationwide Life Insurance Company
this notice? Kansas City, MO 64114
 Other Health-Related Products or Services. We may, from time to time,
use your PHI to determine whether you might be interested in or benefit from
treatment alternatives or other health-related programs, products, or services
which may be available to you as a member of the health plan. For example, we
may use your PHI to identify whether you have a particular illness, and advise
NATIONWIDE® HIPAA NOTICE OF PRIVACY PRACTICES you that a disease management program to help you manage your illness
better is available to you. We will not use your information to communicate
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU with you about products or services which are not health-related without your
MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO written permission.
THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Plan Administration. We may release your PHI to your plan sponsor for
This Notice of Privacy Practices (the “Notice”) applies to Nationwide1 and describes administrative purposes, provided we have received certification that the
the legal obligations of Nationwide, and your legal rights regarding your protected information will be maintained in a confidential manner and not used in any
health information held by Nationwide under the Health Insurance Portability and other manner not permitted by law.
Accountability Act of 1996 (“HIPAA”). Among other things, this Notice describes
how your Protected Health Information (“PHI” as that term is defined below) may Other Uses and Disclosures. We are permitted or required by law to make
be used or disclosed to carry out treatment, payment, or healthcare operations, certain other uses and disclosures of your PHI without your authorization.
or for any other purposes that are permitted or required by law. We may release your PHI for any purpose required by law. This may include
releasing your PHI to law enforcement agencies; public health agencies;
Nationwide is required by HIPAA and certain state laws to maintain the privacy of government oversight agencies; workers compensation; for government
your PHI and to provide you with notice of our legal duties and privacy practices audits, investigations, or civil or criminal proceedings; for approved research
with respect to your PHI. We are required to abide by the terms of this Notice so programs; when ordered by a court or administrative agency; to the armed
long as it remains in effect. Nationwide reserves the right to change the terms of forces if you are a member of the military; and other similar disclosures we are
this Notice and to make the new Notice effective for all PHI maintained by us, as required by law to make.
allowed or required by law. If we make any material change to this Notice, we will
provide you with a copy of the revised Notice by mail to your last-known address OTHER PRIVACY LAWS AND REGULATIONS
on file.
Certain other state and federal privacy laws and regulations may further restrict
Protected Health Information (PHI) includes individually identifiable health access to and uses and disclosures of your personal health information or
information that is created or received by Nationwide and that relates to: (1) your provide you with additional rights to manage such information. If you have
past, present, or future physical or mental health or condition, (2) the provision of questions regarding these rights, please send a written request to your
health care to you, or (3) the past, present, or future payment for the provision of designated contact as explained in the “Contact Information” section, below.
health care to you. PHI includes information of persons living or deceased.
RIGHTS THAT YOU HAVE
USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION
Access to Your PHI. You have the right to copy and/or inspect much of the PHI
Your Authorization. Certain uses and disclosures of PHI require your that we retain on your behalf. All requests for access must be made in writing
authorization. For example, most uses and disclosures of PHI for marketing and signed by you or your personal representative. We may charge you a fee
purposes and disclosures that constitute a sale of PHI require a written if you request a copy of the information. The amount of the fee will be indicated
authorization. Except as outlined below, we will not use or disclose your PHI on the request form. A request form can be obtained by writing your designated
without your written authorization. If you have given us an authorization, you may contact at the address provided in the “Contact Information” section.
revoke it in writing at any time, unless we have already acted on the authorization.
Once we receive your written revocation, it will only be effective for future uses Amendments to Your PHI. You have the right to request that the PHI that we
and disclosures. maintain about you be amended or corrected. We are not obligated to make all
requested amendments but will give each request careful consideration. If the
Disclosures for Treatment, Payment or Health Care Operations. We may information is incorrect or incomplete and we decide to make an amendment or
use or disclose your PHI as permitted by law for your treatment, payment, or correction, we may also notify others who work with us and have copies of the
health care operations. For instance, for your treatment, a doctor or health facility uncorrected record if we believe that such notification is necessary. A request
involved in your care may request information we hold in order to make decisions form can be obtained by writing to your designated contact at the address
about your care. For payment, we may disclose your PHI to our pharmacy benefit provided in the “Contact Information” section.
manager for administration of your prescription drug benefit. For health care
operations, we may use and disclose your PHI for our health care operations, Accounting for Disclosures of Your PHI. You have the right to receive an
which include responding to customer inquiries regarding benefits and claims. accounting of certain disclosures made by us of your PHI. Requests must be
made in writing and signed by you or your personal representative. A request
Family and Friends Involved In Your Care. With your approval, we may from form can be obtained by writing your designated contact at the address provided
time to time disclose your PHI to designated family, friends, and others who are in the “Contact Information” section.
involved in your care or in payment for your care in order to facilitate that person’s
involvement in caring for you or paying for your care. Restrictions on Use and Disclosure of Your PHI. You have the right to
request restrictions on some of our uses and disclosures of your PHI. We will
If you are unavailable, incapacitated, or facing an emergency medical situation consider, but are not required to agree to, your restriction request. A request
and we determine that a limited disclosure may be in your best interest, we may form can be obtained by writing your designated contact at the address provided
share limited PHI with such individuals without your approval. in the “Contact Information” section.

Business Associates. Certain aspects and components of our services are Request for Confidential Communications. You have the right to request and
performed through contracts with outside persons or organizations. At times it we will accommodate reasonable requests by you to receive communications
may be necessary for us to provide your PHI to one or more of these outside regarding your PHI information from us by alternative means or at alternative
persons or organizations. For example, we may disclose your PHI to a business locations. A request form can be obtained by writing your designated contact at
associate to administer claims or to provide support services. In all cases, we the address provided in the “Contact Information” section.
require these business associates by contract to appropriately safeguard the
privacy of your information. Right to be Notified of a Breach. You have the right to be notified in the event
we discover a breach of your unsecured PHI.

1 Nationwide Life Insurance Company®, National Casualty Company and

the area within Nationwide Mutual Insurance Company® that performs
healthcare functions.
Right to a Paper Copy of This Notice. You have the right to a paper copy of this
notice, even if you have requested such copy by e-mail or other electronic means.
Complaints. If you believe your privacy rights have been violated, you can file
a written complaint with your designated contact as explained in the “Contact
Information” section, below. You may also file a complaint with the Secretary of
the U.S. Department of Health and Human Services, Office of Civil Rights, in
writing within 180 days of a violation of your rights. There will be no retaliation for
filing a complaint.
CONTACT INFORMATION
If you have any questions about this Notice, need copies of any forms or require
further assistance with any of the rights explained above, contact us by calling
1-844-207-1930 or mail your request to:
Trip Mate, Inc.
Attn: Privacy Officer
9225 Ward Parkway, Suite 200
Kansas City, MO 64114

EFFECTIVE DATE
This Notice is effective 9/15/2015
Nationwide, the Nationwide framework, and On Your Side are federally registered
service marks of Nationwide Mutual Insurance Company.
NH-0524-J-09152015
 Disclosure Notice:

This plan provides insurance coverage that only applies during the covered trip. You may have coverage from
other sources that provides you with similar benefits but may be subject to different restrictions depending
upon your other coverages. You may wish to compare the terms of this policy with your existing life, health,
home, and automobile insurance policies. If you have any questions about your current coverage, call your
insurer or insurance agent or broker.

Purchasing travel insurance is not required in order to purchase any other products or services offered by the
Travel Retailer.

What A Travel Retailer May Do:

Employees of a Travel Retailer may transact Travel Insurance on our behalf and under our direction, including:

1. Offering/disseminating information on our behalf, including brochures, buyer guides, descriptions of

coverage, and price;
2. Referring specific coverage/feature/benefit questions to us;
3. Disseminating/processing applications for coverage, coverage selection forms, or other similar forms;
4. Collecting premiums on our behalf;
5. Receiving/recording information to share with us;

What A Travel Retailer May Not Do:

The Travel Retailer’s employees:
1. are not qualified or authorized to answer technical questions about the benefits, exclusions or
conditions of any of the insurance offered by the Travel Retailer; or
2. to evaluate the adequacy of a prospective insured’s existing insurance coverage.

Definitions

“Travel Insurance” means coverage for personal risks incidental to planned travel, including one or more of the
following:

Interruption or cancellation of a trip or event;

Loss of baggage or personal effects;
Damage to accommodations or rental vehicles; or
Sickness, accident, disability, or death occurring during travel.

The following are excluded from the definition of Travel Insurance: Major medical plans, which provide
comprehensive medical protection for travelers on trips lasting 6 months or longer (e.g. working overseas,
deployed military personnel, etc.). In some States, Damage waiver contracts that are part of a rental company’s
agreement. The phrase “damage waiver” or “collision damage waiver” cannot be used to describe travel
insurance coverage, but the travel insurance contract may otherwise refer to “damage waiver” or “collision
damage waiver” provided by a rental company.

“We, Us or Our” means Trip Mate, Inc.

DISCLOSURE TO CALIFORNIA RESIDENTS: [1754(a)(7) & (8)]

1. Purchasing travel insurance is not required in order to purchase any other product or service offered by
the travel retailer.
2. Your travel retailer may not be licensed to sell insurance, and is therefore not qualified or authorized to:

a. Answer technical questions about the benefits, exclusions, and conditions of any of the
insurance offered by the travel retailer.
b. Evaluate the adequacy of your existing insurance coverage.

This plan provides insurance coverage that only applies during the covered trip. You may have coverage from
other sources that provide you with similar benefits but may be subject to different restrictions depending upon
your other coverages. You may wish to compare the terms of this policy with your existing life, health, home and
automobile insurance policies. If you have any questions about your current coverage, call your insurer or
insurance agent or broker.

DISCLOSURE TO DELAWARE RESIDENTS: [1772(2)a.7.]

The insurance coverage may duplicate existing coverages you may have. You may wish to compare the terms of
this policy with your existing life, health, home and automobile policies, and other sources of protection.

DISCLOSURE TO MARYLAND RESIDENTS: [10-122 (d)(1)(ii)(4)]

This insurance coverage may duplicate certain provisions of insurance coverage already provided by your
homeowner’s, renter’s or similar coverages or insurances, and that the purchase of travel insurance would make
travel insurance primary to any other duplicate or similar coverage.