Benefits and Rates | Gallagher USA

Student Series

International Semester Students Studying in US

SCHEDULE OF BENEFITS	BENEFIT DESCRIPTION
Plan Type	Gallagher Student Health Series
Coverage Area	Worldwide Excluding Home Country
Rate Guarantee	12 months
Maximum Limit	Per Illness or Injury Maximum Student: $750,000 Dependent: $150,000
	Maximum Limit per Period of Coverage Student: $1,000,000 Dependent: $150,000
Deductible	Outside of US: $25 per illness/injury US PPO Provider: $25 per illness/injury US Non PPO Provider: $50 per illness/injury Student Health Center: $5
Coinsurance (following the applicable Deductible)	Outside of US: Plan pays 100% of Eligible Expenses US PPO Provider or Student Health Center: Plan pays 100% of Eligible Expenses US Non PPO Provider: Plan pays 80% of the first $5,000 of Eligible Expenses, then 100% thereafter

HOSPITAL SERVICES
Inpatient Room & Board	URC*
Intensive Care	URC*
Emergency Room – Injury	URC*
Emergency Room – Illness	URC*; subject to additional $250 deductible
Physical Therapy	URC* limited to 1 visit per day
Prescription Drugs	URC*
Mental & Nervous Disorders (including substance abuse)	URC up to $10,000 lifetime maximum Student Health Center: $0

OUTPATIENT SERVICES
Outpatient Prescription Drugs	50% of actual charges
Outpatient Physical Therapy	URC* limited to 1 visit per day
Outpatient Mental & Nervous Disorders (including substance abuse)	$50 per day; $500 lifetime maximum Student Health Center: $0

OTHER SERVICES
Eligible Medical Expenses	URC*
Durable Medical Equipment	URC*
Local Ambulance	Per injury: Up to $750 Per illness: $750 only if admitted as in-patient
Dental	For Injury due to covered Accident: $500 For Sudden & Unexpected Pain: $350
Maternity	Subject to Special Maternity Pre-Certification requirements, Same as any other illness. Coinsurance: Overseas: 100% In PPO Network: 80% Out of PPO Network: 60%
Routine Newborn Care	$750 maximum per period of coverage
Home Nursing Care (upon direct transfer from acute care Hospital)	URC*
Accidental Death and Dismemberment	Student: $100,000 Spouse: $10,000 Dependent Child: $5,000 Accident Dismemberment percentage of principal sum.
Terrorism Coverage	$50,000 lifetime maximum
Interscholastic/Intercollegiate/ Intramural or Club Sports	$5,000 maximum per injury/illness ENHANCED OPTION - $10,000 maximum per injury/illness; 2.5% rate increase
Incidental Home Country Trip Coverage	Up to (2) cumulative weeks
Pre-existing Conditions	12 month waiting period, that can be reduced with proof of prior creditable coverage
Telemedicine	Included
Benefit/Treatment Period	60 day minimum

EMERGENCY SERVICES
Emergency Medical Evacuation	Up to $500,000 Lifetime Maximum (independent of the Maximum Limit)
Emergency Reunion	Up to $500,000 Maximum
Return of Mortal Remains	Up to $50,000 Maximum
Political Evacuation	Up to $10,000 Lifetime Maximum

Non-US Citizen

	Age	Student	Spouse	Dependent Child
	0 - 30	$90.73	$476.83	$103.40
Platinum	31 - 50	$244.78	$700.10	$103.40
	51 - 64	$531.43	$700.10	$103.40

Non-US Citizen

	Age	Student	Spouse	Dependent Child
	0 - 30	$93.00	$488.75	$105.99
Enhanced	31 - 50	$250.90	$717.60	$105.99
	51 - 64	$544.72	$717.60	$105.99

**Please refer to the Certificate Wording for specific terms, conditions, and other details regarding benefits, limitations, eligibility, and exclusions outlined in this summary. The certificate wording prevails over any information provided in this summary and is available upon request prior to purchase.

US Students Semester Study Abroad

SCHEDULE OF BENEFITS	BENEFIT DESCRIPTION
Plan Type	Gallagher Student Health Series
Coverage Area	Worldwide Excluding Home Country
Rate Guarantee	12 months
Maximum Limit	Per Illness or Injury Maximum Student: $750,000 Dependent: $150,000
	Maximum Limit per Period of Coverage Student: $1,000,000 Dependent: $150,000
Deductible	Outside of US: $25 per illness/injury US PPO Provider: $25 per illness/injury US Non PPO Provider: $50 per illness/injury Student Health Center: $5
Coinsurance (following the applicable Deductible)	Outside of US: Plan pays 100% of Eligible Expenses US PPO Provider or Student Health Center: Plan pays 100% of Eligible Expenses US Non PPO Provider: Plan pays 80% of the first $5,000 of Eligible Expenses, then 100% thereafter

HOSPITAL SERVICES
Inpatient Room & Board	URC*
Intensive Care	URC*
Emergency Room – Injury	URC*
Emergency Room – Illness	URC*; subject to additional $250 deductible
Physical Therapy	URC* limited to 1 visit per day
Prescription Drugs	URC*
Mental & Nervous Disorders (including substance abuse)	URC up to $10,000 lifetime maximum Student Health Center: $0

OUTPATIENT SERVICES
Outpatient Prescription Drugs	50% of actual charges
Outpatient Physical Therapy	URC* limited to 1 visit per day
Outpatient Mental & Nervous Disorders (including substance abuse)	$50 per day; $500 lifetime maximum Student Health Center: $0

OTHER SERVICES
Eligible Medical Expenses	URC*
Durable Medical Expenses	URC*
Local Ambulance	Per injury: Up to $750 Per illness: $750 only if admitted as in-patient
Dental	For Injury due to covered Accident: $500 For Sudden & Unexpected Pain: $350
Maternity	Subject to Special Maternity Pre-Certification requirements, Same as any other illness. Coinsurance: Overseas: 100% In PPO Network: 80% Out of PPO Network: 60%
Routine Newborn Care	$750 maximum per period of coverage
Home Nursing Care (upon direct transfer from acute care Hospital)	URC*
Accidental Death and Dismemberment	Student: $100,000 Spouse: $10,000 Dependent Child: $5,000 Accident Dismemberment percentage of principal sum.
Terrorism Coverage	$50,000 lifetime maximum
Interscholastic/Intercollegiate/ Intramural or Club Sports	$5,000 maximum per injury/illness ENHANCED OPTION - $10,000 maximum per injury/illness; 2.5% rate increase
Incidental Home Country Trip Coverage	Up to (2) cumulative weeks
Pre-existing Conditions	12 month waiting period, that can be reduced with proof of prior creditable coverage
Telemedicine	Included
Benefit/Treatment Period	60 day minimum

EMERGENCY SERVICES
Emergency Medical Evacuation	Up to $500,000 Lifetime Maximum (independent of the Maximum Limit)
Emergency Reunion	Up to $500,000 Maximum
Return of Mortal Remains	Up to $50,000 Maximum
Political Evacuation	Up to $10,000 Lifetime Maximum

US Citizens

	Age	Student	Spouse	Dependent Child
	0 - 30	$72.20	$414.43	$78.05
Platinum	31 - 50	$156.05	$604.55	$78.05
	51 - 64	$335.45	$604.55	$78.05

US Citizens

	Age	Student	Spouse	Dependent Child
	0 - 30	$74.01	$424.79	$80.00
Enhanced	31 - 50	$159.95	$619.66	$80.00
	51 - 64	$343.84	$619.66	$80.00

Short Term Study Outside US (For travel 60 days or less)

BENEFIT	LIMIT	COMMENTS
Accidental Death & Dismemberment	$100,000	Reduced to $10,000 for those under age 12 or age 70 and over
Medical Expenses - Primary $100 deductible No preexisting conditions Exclusion.	$10,000	Primary coverage; $2,500 of this limit is available to pay U.S. or Canadian providers
Excess Medical Expenses - Optional Preexisting conditions are Excluded. Includes an additional $50,000 Emergency Medical Evacuation limit.	$40,000	For those age 0-59 at an additional $0.49 per diem
	$90,000	For those age 0-59 at an additional $0.69 per diem
ExcessMedical Expenses - Optional Preexisting conditions are Excluded. Does NOT include an additional Emergency Medical Evacuation limit.	$40,000	For those age 60-65 at an additional $1.40 per diem
	$40,000	For those age 66-70 at an additional $3.05 per diem
Disability Income Benefit (no benefit if under age 12 or 70 and over)	$1,000/month $500/month $250/month	First 100 Months — Accident Months 101–200 — Accident 50 Months — Sickness (after 3 month waiting period)
Assistance Service	Included	Available 24/7/365 for assistance with worldwide medical emergencies; provided by Intana Global™
Emergency Medical Evacuation	$100,000	Coordinated by Intana Global™; will bring participant back to USA if necessary
Crisis Management Service*	Included	Available 24/7/365 for assistance with worldwide non-medical emergencies; provided by red24
Security Evacuation*	$100,000	Coordinated by red24; for evacuation due to crime, civil unrest, natural disasters, kidnap/hostage situations**
Family Coordination and Repatriation of Mortal Remains	$25,000	Combined limit for both benefits and includes a sublimit of $2,500 for extra expenses incurred during an approved evacuation
Personal Property $100 deductible	$2,500	“Door to door” replacement cost coverage includes checked baggage; higher limits available upon request.
General Liability	$1,000,000	Worldwide jurisdiction; includes coverage for injury to a volunteer; covers volunteer and sending organization
PARTICIPATION FEE	$3.30 per person per day

By requesting that we enroll you or your group, you are agreeing to participate in International Helpers (Guernsey) Trust (IHT) for certain benefits and services. The Trust Participation Agreement is attached for signature and return with enrollment. Services & Benefits are provided by service contracts & insurance policies issued to IHT.

*The cost of a security evacuation is only insured up to $1,000 in countries and regions deemed Extreme Risk by red24, unless the volunteer is already in the country and insured by this plan when the country or region is elevated to Extreme Risk status. red24 cannot guarantee service in Extreme Risk areas. If you are traveling to an area that may be subject to this limitation, please contact us.

** While red24 will deploy a specialist or negotiator as needed, this benefit does not pay ransom amounts.

This brief summary is not an insurance policy; rather, it outlines some of the features of this coverage. For specific details, please contact our office or refer to the policy. This is not a major medical policy. Major Medical Coverage is available for individuals and groups on Short-Term and Long-Term international assignments. An Aggregate Limit of $20,000,000 applies to the above benefits. This limit provides the full $100,000 AD&D benefit for up to 200 persons in a common accident.

To participate and receive the services & benefits of IHT, complete the enrollment form and return along with your check made payable to: Gallagher Charitable International Insurance Services. In computing the number of days, count the departure day as well as the day of return. If the entire group is not traveling on the same dates, please attach a separate sheet grouping the volunteers by their travel dates.

To enroll, please visit www.TravelWithGallagher.com.

Faculty Series

Teaching Outside US

SCHEDULE OF BENEFITS	BENEFIT DESCRIPTION
Plan Type	Gallagher Student Health Series
Coverage Area	Worldwide Excluding Home Country
Rate Guarantee	12 months
Maximum Limit	Per Illness or Injury Maximum Student: $750,000 Dependent: $150,000
	Maximum Limit per Period of Coverage Student: $1,000,000 Dependent: $150,000
Deductible	Outside of US: $25 per illness/injury US PPO Provider: $25 per illness/injury US Non PPO Provider: $50 per illness/injury Student Health Center: $5
Coinsurance (following the applicable Deductible)	Outside of US: Plan pays 100% of Eligible Expenses US PPO Provider or Student Health Center: Plan pays 100% of Eligible Expenses US Non PPO Provider: Plan pays 80% of the first $5,000 of Eligible Expenses, then 100% thereafter

HOSPITAL SERVICES
Inpatient Room & Board	URC*
Intensive Care	URC*
Emergency Room – Injury	URC*
Emergency Room – Illness	URC*; subject to additional $250 deductible
Physical Therapy	URC* limited to 1 visit per day
Prescription Drugs	URC*
Mental & Nervous Disorders (including substance abuse)	URC up to $10,000 lifetime maximum Student Health Center: $0

OUTPATIENT SERVICES
Outpatient Prescription Drugs	50% of actual charges
Outpatient Physical Therapy	URC* limited to 1 visit per day
Outpatient Mental & Nervous Disorders (including substance abuse)	$50 per day; $500 lifetime maximum Student Health Center: $0

OTHER SERVICES
Eligible Medical Expenses	URC*
Durable Medical Equipment	URC*
Local Ambulance	Per injury: Up to $750 Per illness: $750 only if admitted as in-patient
Dental	For Injury due to covered Accident: $500 For Sudden & Unexpected Pain: $350
Maternity	Subject to Special Maternity Pre-Certification requirements, Same as any other illness. Coinsurance: Overseas: 100% In PPO Network: 80% Out of PPO Network: 60%
Routine Newborn Care	$750 maximum per period of coverage
Home Nursing Care (upon direct transfer from acute care Hospital)	URC*
Accidental Death and Dismemberment	Student: $100,000 Spouse: $10,000 Dependent Child: $5,000 Accident Dismemberment percentage of principal sum.
Terrorism Coverage	$50,000 lifetime maximum
Interscholastic/Intercollegiate/ Intramural or Club Sports	$5,000 maximum per injury/illness ENHANCED OPTION - $10,000 maximum per injury/illness; 2.5% rate increase
Incidental Home Country Trip Coverage	Up to (2) cumulative weeks
Pre-existing Conditions	12 month waiting period, that can be reduced with proof of prior creditable coverage
Telemedicine	Included
Benefit/Treatment Period	60 day minimum

EMERGENCY SERVICES
Emergency Medical Evacuation	Up to $500,000 Lifetime Maximum (independent of the Maximum Limit)
Emergency Reunion	Up to $500,000 Maximum
Return of Mortal Remains	Up to $50,000 Maximum
Political Evacuation	Up to $10,000 Lifetime Maximum

US Citizens

	Age	Faculty	Spouse	Dependent Child
	0 - 30	$72.20	$414.43	$78.05
Platinum	31 - 50	$156.05	$604.55	$78.05
	51 - 64	$335.45	$604.55	$78.05

US Citizens

	Age	Faculty	Spouse	Dependent Child
	0 - 30	$74.01	$424.79	$80.00
Enhanced	31 - 50	$159.95	$619.66	$80.00
	51 - 64	$343.84	$619.66	$80.00

Teaching Faculty coming into US

SCHEDULE OF BENEFITS	BENEFIT DESCRIPTION
Plan Type	Gallagher Student Health Series
Coverage Area	Worldwide Excluding Home Country
Rate Guarantee	12 months
Maximum Limit	Per Illness or Injury Maximum Student: $750,000 Dependent: $150,000
	Maximum Limit per Period of Coverage Student: $1,000,000 Dependent: $150,000
Deductible	Outside of US: $25 per illness/injury US PPO Provider: $25 per illness/injury US Non PPO Provider: $50 per illness/injury Student Health Center: $5
Coinsurance (following the applicable Deductible)	Outside of US: Plan pays 100% of Eligible Expenses US PPO Provider or Student Health Center: Plan pays 100% of Eligible Expenses US Non PPO Provider: Plan pays 80% of the first $5,000 of Eligible Expenses, then 100% thereafter

HOSPITAL SERVICES
Inpatient Room & Board	URC*
Intensive Care	URC*
Emergency Room – Injury	URC*
Emergency Room – Illness	URC*; subject to additional $250 deductible
Physical Therapy	URC* limited to 1 visit per day
Prescription Drugs	URC*
Mental & Nervous Disorders (including substance abuse)	URC up to $10,000 lifetime maximum Student Health Center: $0

OUTPATIENT SERVICES
Outpatient Prescription Drugs	50% of actual charges
Outpatient Physical Therapy	URC* limited to 1 visit per day
Outpatient Mental & Nervous Disorders (including substance abuse)	$50 per day; $500 lifetime maximum Student Health Center: $0

OTHER SERVICES
Eligible Medical Expenses	URC*
Durable Medical Equipment	URC*
Local Ambulance	Per injury: Up to $750 Per illness: $750 only if admitted as in-patient
Dental	For Injury due to covered Accident: $500 For Sudden & Unexpected Pain: $350
Maternity	Subject to Special Maternity Pre-Certification requirements, Same as any other illness. Coinsurance: Overseas: 100% In PPO Network: 80% Out of PPO Network: 60%
Routine Newborn Care	$750 maximum per period of coverage
Home Nursing Care (upon direct transfer from acute care Hospital)	URC*
Accidental Death and Dismemberment	Student: $100,000 Spouse: $10,000 Dependent Child: $5,000 Accident Dismemberment percentage of principal sum.
Terrorism Coverage	$50,000 lifetime maximum
Interscholastic/Intercollegiate/ Intramural or Club Sports	$5,000 maximum per injury/illness ENHANCED OPTION - $10,000 maximum per injury/illness; 2.5% rate increase
Incidental Home Country Trip Coverage	Up to (2) cumulative weeks
Pre-existing Conditions	12 month waiting period, that can be reduced with proof of prior creditable coverage
Telemedicine	Included
Benefit/Treatment Period	60 day minimum
EMERGENCY SERVICES
Emergency Medical Evacuation	Up to $500,000 Lifetime Maximum (independent of the Maximum Limit)
Emergency Reunion	Up to $500,000 Maximum
Return of Mortal Remains	Up to $50,000 Maximum
Political Evacuation	Up to $10,000 Lifetime Maximum

Non-US Citizens

	Age	Faculty	Spouse	Dependent Child
	0 - 30	$90.73	$476.83	$103.40
Platinum	31 - 50	$244.78	$700.10	$103.40
	51 - 64	$531.43	$700.10	$103.40

Non-US Citizens

	Age	Faculty	Spouse	Dependent Child
	0 - 30	$93.00	$488.75	$105.99
Enhanced	31 - 50	$250.90	$717.60	$105.99
	51 - 64	$544.72	$717.60	$105.99

Short Term Trips 65+ and Up

BENEFIT	LIMIT	COMMENTS
Accidental Death & Dismemberment	$100,000	Reduced to $10,000 for those under age 12 or age 70 and over
Medical Expenses - Primary $100 deductible No preexisting conditions Exclusion.	$10,000	Primary coverage; $2,500 of this limit is available to pay U.S. or Canadian providers
Excess Medical Expenses - Optional Preexisting conditions are Excluded. Includes an additional $50,000 Emergency Medical Evacuation limit.	$40,000	For those age 0-59 at an additional $0.49 per diem
$90,000	For those age 0-59 at an additional $0.69 per diem
Excess Medical Expenses - Optional Preexisting conditions are Excluded. Does NOT include an additional Emergency Medical Evacuation limit.	$40,000	For those age 60-65 at an additional $1.40 per diem
$40,000	For those age 66-70 at an additional $3.05 per diem
Disability Income Benefit (no benefit if under age 12 or 70 and over)	$1,000/month $500/month $250/month	First 100 Months — Accident Months 101–200 — Accident 50 Months — Sickness (after 3 month waiting period)
Assistance Service	Included	Available 24/7/365 for assistance with worldwide medical emergencies; provided by Intana Global™
Emergency Medical Evacuation	$100,000	Coordinated by Intana Global™; will bring participant back to USA if necessary
Crisis Management Service*	Included	Available 24/7/365 for assistance with worldwide non-medical emergencies; provided by red24
Security Evacuation*	$100,000	Coordinated by red24; for evacuation due to crime, civil unrest, natural disasters, kidnap/hostage situations**
Family Coordination and Repatriation of Mortal Remains	$25,000	Combined limit for both benefits and includes a sublimit of $2,500 for extra expenses incurred during an approved evacuation
Personal Property $100 deductible	$2,500	“Door to door” replacement cost coverage includes checked baggage; higher limits available upon request.
General Liability	$1,000,000	Worldwide jurisdiction; includes coverage for injury to a volunteer; covers volunteer and sending organization
PARTICIPATION FEE	$3.30 per person per day

** While red24 will deploy a specialist or negotiator as needed, this benefit does not pay ransom amounts.

To enroll, please visit www.TravelWithGallagher.com.

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