Georgia Tech Study Abroad

Policy Number

GLM N10892880

Plan Information - Spain Participants (Requiring a Visa)

Questions?

24/7 Emergency
Assistance – Team Assist
Phone: (inside the U.S.)
+1 855-327-1411
(call collect from outside the U.S.)
+001 312-935-1703

Benefit or Claim Questions?
Contact CISI
(9AM-5PM EST Mon-Fri)
Phone: 1-203-399-5130
(toll free) 800-303-8120
Email: Claimhelp@mycisi.com

World Class Coverage Plan Designed For Georgia Tech Study Abroad

This plan is provided by Cultural Insurance Services International
and underwritten by Ace American Insurance Company,
a member of the Chubb Group of Companies

Coverage Summary for Policy #

GLM N10892880

SCHEDULE OF BENEFITS

Coverages and Services	Maximum Limits
TRAVEL ACCIDENT INDEMNITY INSURANCE
Accidental Death and Dismemberment Per Insured Person:
Faculty/Student	$25,000
Spouse	$10,000
Per Child	$5,000
ACCIDENT AND SICKNESS INSURANCE
Medical expenses (per Accident or Sickness)
Deductible	zero
Benefit Maximum for Spain participants (90+days Visa Requirement)	$500,000 at 100%
Benefit Maximum	Unlimited
Extension of Benefits	30 days
Home Country Coverage Limit	$10,000
TRAVEL ASSISTANCE INSURANCE
Emergency Medical Reunion	(incl. hotel/meals, max $150/day) $10,000
Program Fee Refund (Student Only)	$5,000
Quarantine	$2,000
Return of Minor Child(ren)	$2,500
Trip Delay	$500 ($100/day)
Return Ticket (Trip Interruption)	$1,000
Chaperone Replacement Benefit	$5,000
PERSONAL PROPERTY INSURANCE
Lost Checked Baggage	(deduct. $50, $100/item) $250max
EVACUATION AND REPATRIATION INSURANCE
Emergency Medical Evacuation	100% of Covered Expenses Participants in Antarctica $250,000 max
Repatriation of Mortal Remains	$100% of Covered Expenses Participants in Antarctica $250,000 max
Security Evacuation (Comprehensive)	$100,000 ($2.5M Aggregate)
NON-INSURANCE SERVICES
Team Assist Plan (TAP): 24/7 medical, travel, technical assistance

In Case of Emergency

Please contact the Team Assist line by phone at +1 312-935-1703 (collect calls accepted) or email medassist-usa@axa-assistance.us. The TeamAssist Emergency Assistance Provider is AXA Assistance.
Non-Emergency questions may be directed to CISI at 203-399-5132 (toll free 800-303-8120).

Schedule of Benefits
Benefits	Limits
Medical Expenses Limits:
Lifetime/Annual Maximum	Unlimited
Per Accident or Sickness	$250,000
Per Occurrence Deductibles:
Emergency Room Deductible (waived if admitted)	$250
Call-A-Doc	$0
Physician/Outpatient/Dr. Visit	$100
Urgent Care	$50
Walk in Clinic	$25
MRI/CAT Scan	$0
Rx Copay	$0
Pre-Existing Conditions-12 Month Look Back; thereafter up to policy max	Up to $500
Coinsurance Percentage (%)	100% Coinsurance
Prescription Drugs (inpatient/outpatient)	Inpatient: 100% of Covered Expenses Outpatient: 100% of Covered Expenses
Mental Health	Inpatient up to 30 days/Outpatient 30 visits
Pregnancy (conception must occur while covered under this plan)	Treated as any other illness
Physiotherapy	Covered
Chiropractic Care & Therapeutic Services	Up to $500 max, $50 per visit
Emergency Reunion	$15,000 (hospitalized 3 days)
Home Country (Incidental Trips)	$1,000
Trip Delay (applies mid trip as well) 24-hour time	Up $1,500/daily limit $100
Political Evacuation	$10,000
Dental Injury Only	Up to policy max
Palliative Dental	$1,000max/$200 per tooth
24/7 Assistant Services & In-house Crisis Team	Included
Medical Evacuation	$50,000
Repatriation of Remains	$25,000
Accidental Death & Dismemberment	$15,000 ($1M aggregate limit)

Schedule of Benefits
Benefits	Limits
Medical Expenses Limits:
Lifetime/Annual Maximum	Unlimited
Per Accident or Sickness	$2,000,000
Per Occurrence Deductibles:
Emergency Room (waived if admitted)	$250
Call-A-Doc	$0
Physician/Outpatient/Dr. Visit	$50
Urgent Care	$50
Walk in Clinic	$25
MRI/CAT Scan	$0
Rx Copay	$0
Pre-Existing Conditions-12 Month Look Back; thereafter up to policy max	Up to $500
Coinsurance Percentage (%)	100% Coinsurance
Prescription Drugs (inpatient/outpatient)	Inpatient: 100% of Covered Expenses Outpatient: 100% of Covered Expenses
Mental Health	Inpatient up to 30 days/Outpatient 30 visits
Pregnancy (conception must occur while covered under this plan)	Treated as any other illness
Emergency Reunion	$15,000 (hospitalized 3 days)
Physiotherapy	Covered
Chiropractic Care & Therapeutic Services	Up to $500 max, $50 per visit
Home Country (Incidental Trips)	$1,000
Trip Delay (applies mid trip as well) 24-hour time	Up $1,500/daily limit $100
Political Evacuation	$10,000
Dental Injury Only	Up to policy max
Palliative Dental	$1,000max/$200 per tooth
24/7 Assistant Services & In-house Crisis Team	Included
Medical Evacuation	$50,000
Repatriation of Remains	$25,000
Accidental Death & Dismemberment	$15,000 ($1M aggregate limit)
Trip Interruption	$1,000
Personal Liability
Personal Liability Limit	$2,000,000
Liability deductible	$100
Medical Payments to Others	$25,000
Additional Living Expenses	$10,000
Payment of Homeowners Deductible	$1,000
Personal Property	$1,500