Short Term Immigrant Insurance

Short Term Immigrant Insurance	Brochure & Application
Please Print to Your Local Printer - Rates and Application are at the end of the page.

Medical Insurance For new Immigrants to the United States - 3 to a total of 24 Months of Coverage. Short Term Immigrant Insurance is Underwritten by The Insurance Company of the State of Pennsylvania, a member of the AIG group of companies and rated A++ "Superior" by AM Best.

Save time and effort. You do not have to call in order to receive a brochure. All you need to do is print this page. It will be accepted by SRI and is a complete description of Short Term Immigrant Insurance. At the end of the document is an application which can be completed and returned to the insurance company.

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WHY YOU NEED THIS INSURANCE
Unfortunately, as a new resident of the United States, you are not eligible for many domestic medical insurance programs. The majority of insurance companies require that you be a resident of the United States for 6 to 12 months before they allow you to purchase their coverage. In the interim, you may be exposed to financial burden if an unforeseen medical event should occur.
Short Term Immigrant Insurance is designed to offer medical coverage and emergency services to new immigrants to the United States for at least three months.
This brochure is a brief description of Short Term Immigrant Insurance. A complete description is contained in the Program Summary, which will be mailed to you together with you Insurance Confirmation Card after SRI receives your completed application and correct premium.

ELIGIBILITY
Short Term Immigrant Insurance was designed by SRI to protect the recent immigrant. If your Country of Residence was a country other than the United States of America or one of its territories, and you plan to make the United States your new Country of Residence, you are eligible to insure yourself, your spouse, and your unmarried dependent children (over 14 days and under 18 years of age). Maximum age of coverage is 79.
Home Country or Country of Residence is defined as - The country where an eligible person(s) has his/her true, fixed and permanent home and principal establishment.
You must purchase this program within the first 12 months upon your arrival in the United States.

PERIOD OF COVERAGE
As you wait until a domestic insurance company will allow you to apply for coverage under their insurance plan, you need flexibility. You must initially enroll into Short Term Immigrant Insurance for between 3 and 12 months.   After that, you may continue to renew coverage, minimum 3 months at a time, at the premium rate in force at the time of renewal. Total period of coverage for Short Term Immigrant Insurance can not exceed 24 months. See "Renewal" section for more information.
Effective Date - Your coverage will begin on the latest of the following:
    1. Your arrival in the United States; or
    2. The date your Application and premium are received by SRI; or
    3. The date you request on the Application.
Expiration Date - Your coverage will end on the earlier of the following:
    1. The date shown on the Insurance Confirmation Card, for which premium has been paid; or
    2. The date you leave the United States (except for the International Travel Coverage benefit - see below).

Renewal
Short Term Immigrant Insurance must initally be purchased for at least three months. One month before the expiration date, SRI will send a renewal notice to the Address of Correspondence listed on the application. Coverage may then be renewed for a period of time, depending upon your specific need. If you renew the coverage for 3 or more months (up to 12 months at a time), SRI will continue to send renewal notices to you. If you renew the coverage for only 1 or 2 months, SRI will assume that you no longer require the coverage and will not send another renewal notice.

SCHEDULE OF BENEFITS

All coverages, benefits and premiums listed in this brochure are in U.S. Dollar Amounts

Policy Maximum	Option A	$50,000
	Option B	$100,000
	Option C	$250,000 (ages 70 to 79, not available)
	Option D	$500,000 (ages 70 to 79, not available)
Deductible Options		(per person per policy period)
	Option 1	$100
	Option 2	$500 (10% discount)
	Option 3	$1000 (20% discount)
	Option 4	$2500 (30% discount)
	Option 5	$5000 (40% discount)

Coinsurance	Traditional Program: After you pay your selected deductible, the program pays 80% of the next $5000of eligible expenses, then 100% to the selected Policy Maximum. Cost Saver Program: After you pay your selected deductible, the program pays 70% of eligible expenses to the selected Policy Maximum.
Emergency Medical Evacuation	$100,000
Repatriation of Mortal Remains	$20,000
Local Ambulance Expense	$2,500
Accidental Death and Dismemberment	$25,000 Principal Sum for Insured or Insured Spouse, $5,000 for Dependent Child
Hospital Room and Board	Average semi-private room rate up to the selected Policy Maximum
Intensive Care	Average semi-private room rate up to the selected Policy Maximum
Outpatient Medical Expense	Usual, reasonable and customary to the selected Policy Maximum
Benefit Period	six months

DESCRIPTION OF MEDICAL BENEFITS
If you or your insured dependent become sick or injured during the period of coverage and require medical treatment, Short Term Immigrant Insurance will pay, subject to the selected deductible and coinsurance, reasonable and customary charges for Covered Expenses resulting from such occurrence, up to the medical benefit amount selected.

	Covered Expenses
1	Charges made by a hospital for room and board, floor nursing and other services, inclusive of charges for professional services and with the exception of personal services of a non-medical nature; provided, however, that expenses do not exceed the hospital's average charge for semiprivate room and board accommodation, or intensive care when medically necessary.
2	Charges made for diagnosis, treatment and surgery by a physician.
3	Charges made for the cost of administration of anesthetics.
4	Charges for medication, X-ray services, laboratory tests and services, the use of radium and radioactive isotopes, oxygen, blood transfusions, iron lungs, and medical treatment.
5	Charges for physiotherapy, if recommended by a physician for the treatment of a specific disablement and administered by a licensed physiotherapist.
6	Dressings, drugs and medicines that can be obtained upon a written prescription of a physician or surgeon.
7	Hotel room charge, when you, otherwise necessarily confined in a hospital, shall be under the care of a duly qualified physician in a hotel room owing to the unavailability of a hospital room by reason of capacity or distance or to any other circumstances beyond your control.

Benefit Period
Only those expenses specifically described above which are incurred within six months from the onset of an Injury or Sickness and which are not excluded (see "Exclusions") are considered Covered Expenses. Initial treatment of an Injury must occur within 60 days of the accident.

International Travel Coverage
While the purpose of Short Term Immigrant Insurance is to cover new residents to the U.S., coverage is also valid worldwide. International Travel Coverage is limited to 60 days per 12 months of coverage, or pro rata thereof. Insured must be in the United States for at least 6 months before International Travel Coverage is available. Covered Expenses described in (1-7) above which are incurred outside of the United States are limited to a maximum of $50,000, subject to the selected deductible and coinsurance. The Insured may not travel for the purpose of seeking medical treatment.
Emergency Medical Evacuation Expenses
If you or any covered dependents become sick or injured during the period of coverage and it has been determined that an Emergency Medical Evacuation is required to either the nearest medical facility, where appropriate medical treatment can be obtained, or to your Country of Residence, all eligible expenses incurred are covered up to $100,000. An Emergency Medical Evacuation must be recommended by a legally licensed physician who certifies that the severity of the Injury or Sickness necessitates such Emergency Medical Evacuation, and agreed to by you or your representative. All arrangements are to be coordinated by the Assistance Provider.
Repatriation of Mortal Remains Expenses
If Injury or Sickness commencing during the Period of Coverage results in death, all reasonable expenses incurred for preparation and return of the remains to the Country of Residence are covered up to a maximum of $20,000 provided that all arrangements are coordinated by the Assistance Provider.

Accidental Death and Dismemberment (AD&D)
Short Term Immigrant Insurance includes $25,000 coverage for each Insured Person and Insured Spouse and $5,000 for each Dependent Child. If an Injury occurs during your Period of Coverage and results in one of the following losses within 365 days after an accident, Liaison America will pay for loss as follows:
Loss of Life.....Principal Sum; Loss of two Members.....Principal Sum; Loss of one Member......50% Principal Sum
"Member" means hand, foot or eye. Only one amount, the largest to which you are entitled, is paid for all losses resulting from one accident. "Loss" means with regard to hands and feet, actual severance through or above wrist or ankle joints, and with regard to eyes, entire irrecoverable loss of sight. In the event of a loss, benefits will be paid according to the Principal Sum. "Injury wherever used in the policy shall mean bodily injury caused solely and directly by accidental, violent, external, and visible means occurring while the policy is in force and resulting directly and independently of all causes in loss covered by the policy.
Accidental Death & Dismemberment Indemnity loss schedule will be extended to include the following: Quadriplegia (total paralysis of both upper and lower limbs).....Principal Sum. Paraplegia (total paralysis of both lower limbs)....Three-Quarters of the Principal Sum. Hemiplegia (total paralysis of both upper and lower limbs of one side of the body)..... One Half the Principal Sum. Uniplegia (total paralysis of one limb)... One Quarter the Principal Sum. "Loss" shall mean the complete and irreversible paralysis of such limbs.

EXCLUSIONS

For Medical Expense Benefits, this insurance does not cover:

1	Pre-Existing Conditions, defined as any Injury or Illness which was contracted or which manifested itself, or for which treatment or medication was prescribed within three (3) years prior to the Effective Date of this insurance;
2	For services, supplies or treatment, including any period of Hospital confinement, which were not recommended, approved and certified and necessary and reasonable by a Physician;
3	For suicide or any attempt thereat while sane or self destruction or any attempt thereat while insane;
4	Declared or undeclared war or any act thereof;
5	For Injury sustained while participating in professional athletics;
6	For sickness resulting from pregnancy, childbirth, or miscarriage;
7	For miscarriage resulting from accident;
8	For routine physicals or other examinations where there are no objective indications or impairment in normal health, and laboratory diagnostic or x-ray examinations, except in the course of a Disability established by a prior call or attendance of a Physician;
9	For cosmetic or plastic surgery, except as a result of an accident;
10	For elective surgery which can be postponed until the insured returns to his/her Country of Residence;
11	For any mental and nervous disorders or rest cures;
12	For dental care, except as the result of Injury to natural teeth caused by accident;
13	For eye infractions or eye examinations for the purpose of prescribing corrective lenses for eye glasses or for the fitting thereof, unless caused by accidental bodily Injury incurred while insured thereunder;
14	In connection with alcoholism and drug addiction, or use of any drug or narcotic agent;
15	For congenital anomalies and conditions arising out or resulting from thereof;
16	For expenses which are non-medical in nature;
17	For the ordinary cost of a one-way airplane ticket used in the transportation back to the Insured Person's Home Country where an air ambulance benefit is provided;
18	For expenses as a result of or in connection with intentionally self-inflicted Injury;
19	For expenses as a result if or in connection with the commission of a felony offense;
20	For specific named hazards: motorcycle driving, scuba diving, skiing, mountain climbing, ski diving, professional and amateur racing, and piloting an aircraft;
21	Treatment paid for or furnished under any other individual or group policy or other service or medical pre-payment plan arranged through the employer to the extent so furnished or paid, or under any mandatory government program or facility set up for treatment without cost to any individual.

For Accidental Death and Dismemberment, Emergency Medical Evacuation, and Repatriation of Mortal Remains, this insurance does not cover:

1	Suicide or attempt thereof by the Insured Person while sane or self destruction or any attempt thereof by the Insured Person while insane;
2	Disease of any kind;
3	Bacterial infections except pyogenic infection which shall occur through an accidental cut or wound;
4	Hernia of any kind;
5	Injury sustained while the Insured Person is riding as a pilot, student pilot, operator or crew member, in or on, boarding or alighting, from any type of aircraft;
6	Injury sustained while the Insured Person is riding as a passenger in any aircraft (a) not having a current and valid airworthy certificate and (b) not piloted by a person who holds a valid and current certificate of competency for piloting such aircraft;
7	Declared or undeclared war or any act thereof;
8	Service in the military, naval or air service of any country;
9	Flying in any aircraft being used for or in connection with acrobatic or stunt flying, racing or endurance tests;
10	Flying in any rocket-propelled aircraft;
11	Flying in any aircraft being used for or in connection with crop dusting or seeding or spraying, fire fighting, exploration, pipe or power line inspection, any form of hunting or herding, aerial photography, banner towing or any experimental purpose;
12	Flying in any aircraft which is engaged in any flight which requires a special permit or waiver from the authority having jurisdiction over civil aviation, even though granted.
	With regard to Emergency Medical Evacuation and Repatriation of Mortal Remains, exclusions 2,3 & 4 shall not apply.

Refund of Premium
Refund of premium shall be considered only if written request is received by SRI prior to the Effective Date of Coverage. After the Effective Date of Coverage, the premium is considered fully earned and non-refundable.
What You Will Receive
Upon successful enrollment in Short Term Immigrant Insurance, you will receive an information packet from SRI. This packet will include your ID Card and Program Summary The Program Summary describes all the benefits of Short Term Immigrant Insurance in greater detail. In addition, the Program Summary tells you the procedure for submitting claims.
The Insurance Company
The value of your insurance coverage depends upon the seurity behind the policy. Short Term Immigrant Insurance is underwritten by The Insurance Company of the State of Pennsylvania, a member company of the American International Group of Companies (AIG) and is rated A++ "Superior" by the A.M. Best Company.

ENROLLING IN SHORT TERM IMMIGRANT INSURANCE
1. Complete Entire Application
2. Select method of payment.
3. If paying by check or money order, make payable to: "SRI" and enclose it together with completed Application.
4. If paying by credit card, complete Application and mail or fax to SRI. Be sure to sign Method of Payment section.

Complete and return the Application with your payment for the total premium to:
SRI
9200 Keystone Crossing, Ste 300
Indianapolis, IN 46240
E-mail notification that you have applied to pierre@assurance-reseau.com
(You may fax if paying by credit card only. Originals are not required if applications is faxed to SRI with credit card payment)
For more information please contact www.assurance-reseau.com
Pierre Granger
e-mail: pierre@assurance-reseau.com
PH: 1-954-328-6750 FAX: 1-305-556-3680

Monthly Premiums (Effective March 1, 2002)

Base Deductible of $100

Traditional Program
Program pays 80% of the first $5,000, then 100% to selected maximum.
	Option A	Option B	Option C	Option D
Age	$50,000	$100,000	$250,000	$500,000
15 days to 20	$40	$50	$61	$81
21 - 29	$46	$58	$73	$90
30 - 39	$76	$87	$103	$130
40 - 49	$119	$134	$150	$186
50 - 59	$163	$182	$216	$252
60 - 69	$210	$236	$272	$306
70 - 79	$420	$525	N/A	N/A
Dep. Child	$29	$36	$45	$57

Cost Saver Program
Program pays 70% of all expenses up to the selected maximum.
	Option A	Option B	Option C	Option D
Age	$50,000	$100,000	$250,000	$500,000
15 days to 20	$29	$36	$45	$59
21 - 29	$34	$43	$53	$66
30 - 39	$55	$64	$76	$95
40 - 49	$86	$98	$109	$135
50 - 59	$119	$133	$157	$183
60 - 69	$154	$172	$199	$224
70 - 79	$306	$384	N/A	N/A
Dep. Child	$21	$27	$33	$42

Dep. Child rate is applicable when at least one parent will also be covered under Short Term Immigrant Insurance.

Please be aware that this is not a general health insurance policy, but an interim travel medical program intended for use while waiting to be eligible for domestic U.S. medical coverage. Short Term Immigrant Insurance does not guarantee payment to a facility or individual for medical expenses until the Company determines that it is an eligible expense.

Application- Short Term Immigrant Insurance
Agent: Pierre Granger # 6643

OFFICIAL USE ONLY: Cert#: Processed: Eff Date: GA:6643

Applicant Information

Mr. Mrs. Miss Last Name: ______________________ First Name: _________________

Where would you like the Program Summary and Insurance Confirmation Card Sent? Address in United States:

Address: ___________________________________________________________________________

City/State/Zip: _______________________________________________________________________

Home Phone: ______________________________ Work Phone: _____________________________

Passport Number: ______________________________ Issuing Country: ________________________

Beneficiary: __________________________________ Relationship: ____________________________

When did or will you arrive in the United States: Month ______ Day _____ Year _____. Date you would like coverage to begin: Month:____ Day:____ Year:____

Have you purchased insurance through SRI before? (circle) Yes No Please note: Your coverage must begin within twelve (12) months of your arrival in the United States. The minimum period of coverage is 3 months and renewable for a maximum period of 24 months. Coverage cannot begin until your arrival in the United States, nor will coverage begin until SRI receives your application and correct premium.

Calculating Your Premium - Please complete entire section

Select Policy Maximum (circle) - Plan A: $50,000 Plan B: $100,000 Plan C: $250,000 Plan D: $500,000

Select Program Type (circle)-

Traditional Program
Program pays 80% of the first $5,000, then 100% to selected maximum

Cost Saver Program
Program pays 70% of all expenses up to selected maximum.

Names of Persons to be Insured

Date of Birth

Monthly Premium

Applicant: ____________________

___/___/___

__________

Spouse: _____________________

___/___/___

__________

Child: _______________________

___/___/___

__________

Child: _______________________

___/___/___

__________

Child: _______________________

___/___/___

__________

Totals:

Select Deductible (circle)	Deductible Discount Factor
Option 1 $100	1.00
Option 2 $500	.90
Option 3 $1000	.80
Option 4 $2500	.70
Option 5 $5000	.60

Total from Box a Above (totals)

Number of months

Deductible Discount Factor

Total Payment Enclosed

Method of Payment: (Please circle)	Check Money Order MasterCard Visa
Card# ___________________________________	Expiration Date: _______________________
Daytime Phone: ____________________________	Billing Address: _______________________
Name on Card: _____________________________	___________________________________
Signature: _____________________________________ (the Signature is required)

Make Check or Money Order Payable to: "SRI". Total Payment for the Full Term of coverage requested must be paid in U.S. Dollars at the time application for coverage is made. Coverage purchased by credit card is subject to validation and acceptance by credit card company.

I declare that I understand the terms and conditions of this product, as outlined in this brochure.

I hereby subscribe to the AIG Life Trust and enroll in the group coverage for which I am eligible under the group contract issued by The Insurance Company of the State of Pennsylvania, a member of the American International Group, Inc. (AIG).

___________________________________________________________ ____________________

Signature of Insured or Proxy (Required) Date

For more information please contact:
Pierre Granger AAI,CIRMS
Managing General Agent
Assurance Internationale Website www.assurance-reseau.com
E-Mail: Pierre Granger

PH: 1-(954) 328-6750
Fax: 1-(305) 556-3680

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