International Marine Medical InsuranceSM

S E R I E S

A worldwide benefits program designed for groups of two
or more professional marine captains and crew members

WWW.IMGLOBAL.COM

Understanding your market.
Exceeding your expectations.
It’s rare to find an insurance provider that offers flexible, specialized
products and associated services for the marine industry. Even rarer
is to find a company with the dedication, resources, and ability toprofessionally administer medical care benefits and deliver claims cost
containment on a global basis. However, at IMG® (International Medical
Group®), we understand the unique needs of marine crew professionals.
In fact, we have an entire marine division dedicated to it. Since 1990, ourteam has provided specialized insurance programs for captains, officers,
and crew members. One such program is the International Marine
Medical InsuranceSM (IMMI) plan. This customizable plan offers medical
coverage to groups of two or more marine crew professionals who live
and work aboard ocean going vessels. The IMMI program, coupled with

our expertise in marine claims, medical management, and international
assistance services, will help you and your crew members properly
prepare for injury or illness that occurs while on assignment.
With IMG, you will rest assured knowing that we have a dedicateddepartment working to keep your insurance as affordable as possible.
The costs of health care are rising, but we are committed to controllingthose costs. You need the proper worldwide coverage, provided by acompany that’s there for you when you need us most. When you selectInternational Marine Medical InsuranceSM, you receive IMG’s promise todeliver exceptional medical benefits, medical assistance, and service—all
designed to give you Global Peace of Mind®.

Plan Highlights» Customizable Solutions IMG offers the flexibility to customize benefits» Medical Travel Management Giving the member who is contemplating

and is available in $US or €EUR. Please contact your insurance producer
for more information, and we will work closely with you to design abenefits package that meets your unique needs.
» International Care Management Our experienced medical
management team can help coordinate care for your members who
have highly complex cases requiring detailed management. These
services may include assisting with:
 Concurrent review and monitoring of services for medical necessity
 Coordination of the hospitalization and any necessary postdischarge carenon-emergency medical treatment in the United States the opportunity
to be financially compensated for having that care rendered by aqualified medical provider(s) outside of the U.S. Following evaluation, acase manager will assist the member in identifying a qualified medical
provider to provide the specified care. Upon approval, the casemanager will coordinate the necessary services including patient care,travel, scheduling, and housing. When treatment is received outside of
the U.S. and there is cost savings greater than $10,000 to the plan, themember will personally share in any cost savings that are realized.

M y I M G SM M e m b e r P o r t a l
It’s easy to access and manage your IMG accounts any time, from anywhere and any
device, via MyIMG.
MyIMG features include:» Claims submission and management» Explanation of Benefit (EOB) access» ID Card and insurance documents » Customer Care live chat and contact
accessinformation» Preauthorisation process initiation» Find a Doctor locator

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S M( I M M I )TheAdvantageSERVICE

Our Service, Strength, and Safety Solutions provide youwith the ultimate advantage: Global Peace of Mind.

Help when and where you need it.

STRENGTH

A market leader you can trust.

You can feel confident with IMG knowing our industry expertise has led us
to serve millions of customers worldwide since 1990. Owned by SiriusPoint,a multi-billion-dollar insurance industry leader and rated “A-” by A.M.
Best, an independent analyst of the insurance industry, IMG has a strong
financial backing and vision to become the preeminent provider of travel
and health safety solutions. With loyal customers ranging from Fortune
500 companies, universities, to individuals and other insurance companies,
our personalized offerings allow us to meet the needs of nearly anyone
traveling internationally.

Nobody wants to experience an emergency while traveling theworld, but if you do, you’ll want a team you can trust to have yourback. IMG’s expert staff is here for you 24/7. We’re accustomed
to working in multiple time zones, languages, and currencies, so
rest assured we have the training to assist you—even in remoteand hazardous locations. Our international and U.S. provider
networks include more than one million physicians and facilities
across the globe, giving you access to quality care while awayfrom your primary care team. Our innovative technology allows
you to manage your claims, your account, and search for providers
through our online portal and mobile app around the clock.

Safety Solutions
Pursuing an education away from your home country is already stressful. We know your safety while studying abroad is important to you, so IMG’s
International Marine Medical InsuranceSM has solutions designed to protect you and give you Global Peace of Mind.

PHYSICAL HEALTH

FINANCIAL PROTECTION

You can’t plan when you get sick, and unfortunately, it
can happen anytime and anywhere. Medical bills canbe expensive, and IMG plans provide the cross-border
medical coverage you need for unexpected medical careand routine visits.

Costs can add up while seeking medical treatment.
However, access to IMG’s international physician andprovider networks and pharmacy discount programs canhelp you save on out-of-pocket medical expenses andprescription medications.

MENTAL WELLNESSCRISIS SUPPORT

Being away from your support system can be challenging.
IMG provides access to mental health services, like virtual
counseling, to help with the transition as you adapt tocultural differences, adjust to a change in education, andnavigate new relationships while you’re away from loved
ones.

Navigating an emergency in a foreign country is never easy.
That’s why IMG offers a range of assistance benefits andservices designed to support you in a crisis. A dedicatedteam of multilingual nurses, doctors, and case managers
provide 24/7 assistance services to facilitate a response tourgent and emergency situations, such as evacuations or
search and rescue missions.

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Medical Benefits Summary
Coverage Limit/Maximum Amount for Eligible Medical Expenses
United States

Plan Details
Maximum Limit

United States

United States

International$1,000,000/$5,000,000 per period of coverage
The Medical Concierge Service is a proprietary service of IMG that helps an insured person
navigate the United States healthcare system to identify the highest quality providers forscheduled inpatient and certain outpatient treatments.

Medical Concierge
 Non-emergency services only

Refer to the MEDICAL CONCIERGE provision for further details.

Benefit Plan Features
Benefit Levels

United States

United States

United States

International

Medical Concierge

In-Network

Out-of-Network

International

PLAN DETAILS

Deductible for Eligible Medical Expenses
Deductible$0$0$100 - $10,000$100 - $10,000

Family Deductible
 Maximum 3 deductibles per family$0$0

3 deductibles

3 deductibles

Coinsurance for Eligible Medical Expenses
Coinsurance In addition to deductible
Out-of-Pocket Maximum

Plan pays 100%,
Insured pays 0%

Plan pays 100%,
Insured pays 0%

Plan pays 80%,
Insured pays 20%

Plan pays 100%,
Insured pays 0%$0$0$1,000$0Precertification
 Transplants: No coverage if precertification requirements are not met.
 Interfacility Ambulance Transfer: No coverage if precertification requirements are not met.
 Emergency Medical Evacuation: No coverage if precertification requirements are not met. Refer to the EMERGENCY MEDICAL EVACUATION provision for






further details and requirements.
Maternity and Newborn Care: 50% reduction of eligible medical expenses if precertification requirements are not met.
All other Treatments & Supplies: 50% reduction of eligible medical expenses if precertification requirements are not met.
Deductible is taken after reduction.
Coinsurance is applied to remainder of the reduced amount.
Refer to PRECERTIFICATION REQUIREMENTS provision for a complete list of services that require precertification.

Pre-Existing Conditions

Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Maximum Limits per Calendar Year or, if indicated, per Lifetime

Benefit
Sudden and Unexpected Reoccurrence of
Pre-Existing Conditions
 Up to the calendar year maximum limit Available for the first 12 months if no priorcreditable coverage

Medical Concierge(Non-emergency)

In-Network

Out-of-Network

International

Not applicable

100%

80%

100%

All coverage and benefits in the plan are in United States (U.S.) dollars. Benefits are subject to the exclusions and limitations and are payable only at Usual, Reasonable, and Customary
charges. This is a summary of a selection of plan benefits offered only as an illustration and does not supersede in anyway the Certificate of Insurance and governing policy documents(together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.

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S M( I M M I )Inpatient or Outpatient Services
Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Maximum Limits per Calendar Year or, if indicated, per Lifetime

Medical Concierge(Non-emergency)

In-Network

Out-of-Network

International

Eligible Medical Expenses

100%

100%

80%

100%

Physician Visits/Services

Not applicable

100%

80%

100%

 Injury: Not subject to emergency room deductible
 Illness: Subject to a $250 deductible for each

Not applicable

100%

80%

Not applicable

Hospital Emergency Room: International

Not applicableNot applicableNot applicable

100%

100%

100%

80%

100%

100%

100%

80%

100%

BenefitHospital Emergency Room: United States

emergency room visit for treatment that does not
result in a direct hospital admission

Hospitalization/Room & Board Average semi-private room rate Includes nursing, miscellaneous and ancillary
services

PHYSICAL HEALTH

Intensive Care
COVID-19/SARS-CoV-2 Coverage
Outpatient Surgical/Hospital Facility

Charges for treatment resulting from COVID-19/SARS-CoV-2 are covered as any other illness
covered under the policy.
100%

100%

80%

100%

Not applicable

100%

80%

100%

Radiology/X-Ray

100%

100%

80%

100%

Chemotherapy/Radiation Therapy

100%

100%

80%

100%

Not applicable

100%

80%

100%

100%

100%

80%

100%

100%

100%

80%

100%

100%

100%

80%

100%

Not applicable

100%

80%

100%

100%

100%

80%

100%

Not applicable

100%

80%

100%

Not applicable

100%

80%

100%

Not applicable

100%

80%

100%

Laboratory

Pre-Admission Testing
Surgery
Reconstructive Surgery
 Surgery is incidental to and follows surgery thatwas covered under the plan
Assistant Surgeon
 20% of the primary surgeon’s eligible fee
Second Surgical Opinion

 Payable at 100% if requested by the Company
 50% reduction of eligible medical expenses for

failure to obtain a second surgical opinion whenrequired by the Company

Anesthetists
Pregnancy and Newborn Care

 After 10 months of continuous coverage Result of natural insemination
 Newborn routine care, diagnostic tests, and routine
immunizations for the first 31 days of life
Pregnancy Complications
 After 10 months of continuous coverage
Durable Medical Equipment

All coverage and benefits in the plan are in United States (U.S.) dollars. Benefits are subject to the exclusions and limitations and are payable only at Usual, Reasonable, and Customary
charges. This is a summary of a selection of plan benefits offered only as an illustration and does not supersede in anyway the Certificate of Insurance and governing policy
documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.

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Inpatient or Outpatient Services (continued)
Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Maximum Limits per Calendar Year or, if indicated, per Lifetime

Benefit
Podiatry Care Maximum Limit: $750
Chiropractic Care (Outpatient)
Not subject to deductible and coinsurance
Maximum limit per visit: $75
Maximum visits: 20
Physician order not required
Chiropractic Care (Inpatient) Must be part of recovery treatment plan for acovered illness or injury
 Medical order or treatment plan required
Physical Therapy
 Not subject to coinsurance
 Maximum limit per visit: $75
 Medical order or treatment plan required
Occupational Therapy
 Not subject to coinsurance
 Maximum limit per visit: $75
 Medical order or treatment plan required
Extended Care Facility
 Upon direct transfer from acute care facility
Home Nursing Care
 Provided by a home health care agency
 Upon direct transfer from an acute care facility
Transplant Lifetime maximum: $1,000,000
 Per period of coverage transplant maximum
limit: 1
 Organ procurement & harvesting costs lifetime
maximum: $10,000
 Travel & lodging lifetime maximum expense: $5,000
 Covered transplants: cornea, heart, heart/lung,
lung, kidney, kidney/pancreas, liver, allogeneic or
autologous bone marrow Subject to the TRANSPLANT PRECERTIFICATION
provision and only when treatment is provided
within the Company’s approved independent
Managed Transplant System Network

PHYSICAL HEALTH






Medical Concierge(Non-emergency)

In-Network

Out-of-Network

International

Not applicable

100%

80%

100%

Not applicable

100%

100%

100%

Not applicable

100%

80%

100%

Not applicable

100%

100%

100%

Not applicable

100%

80%

100%

100%

100%

80%

100%

100%

100%

80%

100%

100%

100%

80%

100%

Preventative CareNOT Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Maximum Limits per Calendar Year or, if indicated, per Lifetime

Benefit

Medical Concierge(Non-emergency)

In-Network

Out-of-Network

International

Not applicable

100%

100%

100%

Not applicable

100%

100%

100%

Adult Preventative Care Ages 19 and over
 Maximum limit: $250
 Refer to the PREVENTATIVE CARE provision forfurther details and requirements
Child Preventative Care Ages 18 and younger Maximum limit: $250
 Refer to the PREVENTATIVE CARE provision forfurther details and requirements

All coverage and benefits in the plan are in United States (U.S.) dollars. Benefits are subject to the exclusions and limitations and are payable only at Usual, Reasonable, and Customary
charges. This is a summary of a selection of plan benefits offered only as an illustration and does not supersede in anyway the Certificate of Insurance and governing policy documents(together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.

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S M( I M M I )Vision CarePHYSICAL HEALTHNOT Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Maximum Limits per Calendar Year or, if indicated, per Lifetime

Routine Eye Examination

Maximum limit every 24 months: $100

 Available after 12 months of continuous coverage
Corrective Lenses, Contacts, Frames

Maximum limit every 24 months: $150

 Available after 12 months of continuous coverage
Prescriptions

Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Maximum Limits per Calendar Year or, if indicated, per Lifetime

BenefitPrescriptions

 Dispensing maximum: 90 days per prescription

Medical Concierge(Non-emergency)

In-Network

Out-of-Network

International

Not applicable

80%

80%

100%

Out-of-Network

International

Mental or Nervous, Substance Abuse and Counseling

MENTALWELLNESS

Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Maximum Limits per Calendar Year or, if indicated, per Lifetime

Medical Concierge(Non-emergency)

Benefit

In-Network

Lifetime Maximum$20,000

Inpatient Mental or Nervous/Substance Abuse

100%

100%

80%

100%

Not applicable

100%

80%

100%

Outpatient Mental or Nervous/Substance Abuse Maximum limit per visit: $100
 Maximum visits: 52

Emergency Services
NOT Subject to Deductible or Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Maximum Limits per Calendar Year or, if indicated, per Lifetime

Benefit

Medical Concierge(Non-emergency)

In-Network

Out-of-Network

International

Not applicable

100%

80%

100%

Not applicable

100%

100%

100%

Not applicable

100%

100%

100%

Not applicable

100%

100%

100%

Not applicable

100%

100%

100%

Emergency Local Ambulance

CRISIS SUPPORT Subject to deductible and coinsurance Injury Illness resulting in an inpatient hospital admission
Emergency Medical Evacuation

 Lifetime maximum: $1,000,000
 Insured persons under 65 years of age
 Approved in advance and coordinated by theCompany
Emergency Reunion Lifetime maximum: $10,000
 Maximum days: 15
 Maximum meal limit per day: $25
 Reasonable and necessary travel costs andaccommodations
 Approved in advance by the Company
Interfacility Ambulance Transfer
 Transfer must be a result of an inpatient hospital
admission
Return of Mortal Remains

 Maximum limit: $25,000
 Local burial/Cremation maximum limit: $10,000
 Return of insured person’s mortal remains to homecountry Approved in advance by the Company
All coverage and benefits in the plan are in United States (U.S.) dollars. Benefits are subject to the exclusions and limitations and are payable only at Usual, Reasonable, and Customary
charges. This is a summary of a selection of plan benefits offered only as an illustration and does not supersede in anyway the Certificate of Insurance and governing policy
documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.

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Other Services

FINANCIAL PROTECTIONNOT Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Maximum Limits per Calendar Year or, if indicated, per Lifetime

Benefit

Medical Concierge(Non-emergency)

In-Network

Out-of-Network

International

Not applicable

100%

100%

100%

Not applicable

100%

100%

100%

Not applicable

100%

100%

100%

Not applicable

100%

80%

100%

Not applicable

80%

80%

100%

Not applicable

100%

80%

100%

Accommodation Benefit

 Maximum limit: $2,500
 Refer to the ACCOMMODATION BENEFIT provisions
for futher details and requirements

Crew Member Return Maximum limit: $2,500
Supplemental Accident Benefit

 Maximum limit per covered accident: $300
Amateur Sailboat Racing Subject to deductible and coinsurance
Emergency Dental

 Subject to deductible and coinsurance Accident related
Traumatic Dental Injury

 Treatment at a hospital facility due to an accident
 Additional treatment for the same injury rendered
by a dental provider will be paid at 100%PHYSICAL HEALTH

Hospital Indemnity

 International only Benefit is not available when the inpatient

hospital treatment is part of the Medical Travel
Management benefit Inpatient hospitalization only

 Overnight maximum limit: $100
 Maximum overnight limit: 20
 Maximum limit: $2,000

Teleconsulation**

Company pays 100%
Medically necessary non-emergency treatment, including hospitalization and surgery for approved
procedures; the Company will offer medical travel as a means to manage the costs.

Medical Travel Management
 Must be approved in advance by the Company

If Medical Travel is approved, the Company will reimburse 10% of the cost savings, up to a maximumof $7,500 back to the Insured Person where such savings arise from Treatment outside of the UnitedStates.
Meal allowance maximum: $100
Refer to the MEDICAL TRAVEL MANAGEMENT provision for further details and requirements.

Non-Emergency Medical Evacuation

 Lifetime maximum: $1,000,000
 Insured persons under age 65
 Approved in advance and coordinated by the

Not applicable

100%

100%

100%

Not applicable

100%

80%

100%

Company

Recreational Underwater Activities
MENTALWELLNESS Subject to deductible and coinsurance
Remote Mental Health Service*

Company pays 100%

 Employee Assistance Program*Coverage for Remote Mental Health Service is not a determination that any specific condition discussed, raised, or identified during such consultation is covered under this insurance. The
Company reserves the right to decline future claims relating to or arising from any condition discussed, raised, or identified during a Consultation where the illness or injury is directly or
indirectly related to any pre-existing condition or is otherwise excluded under this Certificate of Insurance.
**Teleconsultation will not support a diagnosis for Mental or Nervous disorders. Coverage for a Teleconsultation is not a determination that any specific condition discussed, raised, or
identified during such consultation is covered under this insurance. The Company reserves the right to decline future claims relating to or arising from any condition discussed, raised, or
identified during a Teleconsultation where the illness or injury is directly or indirectly related to any pre-existing condition or is otherwise excluded under this Certificate of Insurance.
All coverage and benefits in the plan are in United States (U.S.) dollars. Benefits are subject to the exclusions and limitations and are payable only at Usual, Reasonable, and Customary
charges. This is a summary of a selection of plan benefits offered only as an illustration and does not supersede in anyway the Certificate of Insurance and governing policy documents(together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.

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S M( I M M I )Dental Benefits Summary
Coverage Limit/Maximum Amount for Eligible Dental Expenses
Calendar Year Maximum Limit$1,000 - $1,500 - $3,000

Calendar Year Orthodontia Maximum Limit$1,000 - $1,500 - $3,000

Deductible$50

 Applies to minor restorative, major restorative, and orthodontia services
Family Deductible$150

 Maximum 3 deductibles per family
Routine Services
NOT Subject to Deductible and Coinsurance unless otherwise noted
Eligible Expenses are limited to Usual, Reasonable, and Customary
Maximum Limits per Calendar Year or, if indicated, per Lifetime

BenefitCoinsurance

Diagnostic and Preventative Services

 Preventative visits and cleanings: 2(1 every 6 months)

 Radiographic examinations (including posterior bitewings): 2

Plan pays 100%

Insured pays 0%

Plan pays 100%

Insured pays 0%(1 every 6 months)

PHYSICAL HEALTH Fluoride treatment: 1 for children under age 19
Emergency Palliative Treatment

Minor Restorative
Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Maximum Limits per Calendar Year or, if indicated, per Lifetime

Radiographs

 Radiograph: 1 every 3 years
 Full mouth x-rays including panographic x-rays

Plan pays 80%

Insured pays 20%

Oral Surgery

Plan pays 80%

Insured pays 20%

Endodontics

Plan pays 80%

Insured pays 20%

Plan pays 80%

Insured pays 20%

Plan pays 80%

Insured pays 20%

Periodontics

 Root planning: 1 every 2 years
 Periodontal surgery: 1 every 3 years
Minor Restorative Services

 Refer to the ELIGIBLE DENTAL EXPENSES provision for further details andrequirements

Major Restorative
Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Maximum Limits per Calendar Year or, if indicated, per Lifetime

Major Restorative Services

 Crowns, jackets, inlays (on same tooth): 1 every 5 years
 Limitations apply for children under age 12
 Refer to the ELIGIBLE DENTAL EXPENSES provision for further details andPlan pays 50%

Insured pays 50%

Plan pays 50%

Insured pays 50%

requirements

Prosthodontics

 Dentures/bridges: 1 every 5 years
 Replacement of denture base material or reline: 1 every 3 years Refer to the ELIGIBLE DENTAL EXPENSES provision for further details andrequirements

Orthodontia Services
Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Maximum Limits per Calendar Year or, if indicated, per Lifetime

Orthodontia

Plan pays 50%

 Children under age 19

Insured pays 50%

All coverage and benefits in the plan are in United States (U.S.) dollars. Benefits are subject to the exclusions and limitations and are payable only at Usual, Reasonable, and Customary
charges. This is a summary of a selection of plan benefits offered only as an illustration and does not supersede in anyway the Certificate of Insurance and governing policy
documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.

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S M( I M M I )P L A T I N U M Medical Benefits Summary
Coverage Limit/Maximum Amount for Eligible Medical Expenses
Period of Coverage

Maximum Limit: 365 days

Calendar Year Maximum Limit

Unlimited

Medical Concierge
 Non-emergency services only

The Medical Concierge Service is a proprietary service of IMG that helps an insured person
navigate the United States healthcare system to identify the highest quality providers forscheduled Inpatient and certain outpatient treatments.
Refer to the MEDICAL CONCIERGE provision for further details.

Benefit Plan Features
Benefit Levels

United States

United States

United States

International

Medical Concierge

In-Network

Out-of-Network

International$0$0Deductible for Eligible Medical Expenses
PLAN DETAILS

Deductible$0$0

Coinsurance for Eligible Medical Expenses
Coinsurance In addition to deductible
Out-of-Pocket Maximum

Plan pays 100%,
Insured pays 0%

Plan pays 100%,
Insured pays 0%

Plan pays 80%,
Insured pays 20%

Plan pays 100%,
Insured pays 0%$0$0$1,000$0Precertification
 Transplants: No coverage if precertification requirements are not met.
 Interfacility Ambulance Transfer: No coverage if precertification requirements are not met.
 Emergency Medical Evacuation: No coverage if precertification requirements are not met. Refer to the EMERGENCY MEDICAL EVACUATION provision for






further details and requirements.
Maternity and Newborn Care: 50% reduction of eligible medical expenses if precertification requirements are not met.
All other Treatments & Supplies: 50% reduction of eligible medical expenses if precertification requirements are not met.
Deductible is taken after reduction.
Coinsurance is applied to remainder of the reduced amount.
Refer to PRECERTIFICATION REQUIREMENTS provision for a complete list of services that require precertification.

Pre-Existing Conditions
Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Maximum Limits per Calendar Year or, if indicated, per Lifetime

Pre-existing conditions are covered the same as any other illness or injury.

All coverage and benefits in the plan are in United States (U.S.) dollars. Benefits are subject to the exclusions and limitations and are payable only at Usual, Reasonable, and Customary
charges. This is a summary of a selection of plan benefits offered only as an illustration and does not supersede in anyway the Certificate of Insurance and governing policy
documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.

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Inpatient or Outpatient Services
Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Maximum Limits per Calendar Year or, if indicated, per Lifetime

Medical Concierge(Non-emergency)

In-Network

Out-of-Network

International

Eligible Medical Expenses

100%

100%

80%

100%

Physician Visits/Services

Not applicable

100%

80%

100%

Hospital Emergency Room: United States Injury: Not subject to emergency room deductible
 Illness: subject to a $250 deductible for each
emergency room visit for treatment that does not
result in a direct hospital admission

Not applicable

100%

80%

Not applicable

Hospital Emergency Room: International

Benefit

Not applicableNot applicableNot applicable

100%

Hospitalization/Room & Board Average semi-private room rate Includes nursing, miscellaneous and ancillary
services

100%

100%

80%

100%

Intensive Care

100%

100%

80%

100%

PHYSICAL HEALTH

COVID-19/SARS-CoV-2 Coverage
Outpatient Surgical/Hospital Facility

Charges for treatment resulting from COVID-19/SARS-CoV-2 are covered as any other illness
covered under the policy. All other pandemic exclusions apply.
100%

100%

80%

100%

Not applicable

100%

80%

100%

Radiology/X-Ray

100%

100%

80%

100%

Chemotherapy/Radiation Therapy

100%

100%

80%

100%

Not applicable

100%

80%

100%

100%

100%

80%

100%

100%

100%

80%

100%

100%

100%

80%

100%

Not applicable

100%

80%

100%

100%

100%

80%

100%

Not applicable

100%

80%

100%

Not applicable

100%

80%

100%

Durable Medical Equipment

Not applicable

100%

80%

100%

Podiatry Care Maximum Limit: $750

Not applicable

100%

80%

100%

Laboratory

Pre-Admission Testing
Surgery
Reconstructive Surgery
 Surgery is incidental to and follows surgery that wascovered under the plan
Assistant Surgeon
 20% of the primary surgeon’s eligible fee
Second Surgical Opinion
 Payable at 100% if requested by the Company
 50% reduction of eligible medical expenses for
failure to obtain a second surgical opinion whenrequired by the Company
Anesthetists
Pregnancy and Newborn Care

 After 10 months of continuous coverage Result of natural insemination
 Newborn routine care, diagnostic tests, and routine
immunizations for the first 31 days of life
Pregnancy Complications
 After 10 months of continuous coverage

All coverage and benefits in the plan are in United States (U.S.) dollars. Benefits are subject to the exclusions and limitations and are payable only at Usual, Reasonable, and Customary
charges. This is a summary of a selection of plan benefits offered only as an illustration and does not supersede in anyway the Certificate of Insurance and governing policy documents(together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.

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S M( I M M I )Inpatient or Outpatient Services (continued)
Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Maximum Limits per Calendar Year or, if indicated, per Lifetime

Benefit
Chiropractic Care (Outpatient)
Not subject to deductible and coinsurance
Maximum limit per visit: $75
Maximum visits: 20
Physician order not required






Medical Concierge(Non-emergency)

In-Network

Out-of-Network

International

Not applicable

100%

100%

100%

Not applicable

100%

80%

100%

Not applicable

100%

100%

100%

Not applicable

100%

80%

100%

100%

100%

80%

100%

100%

100%

80%

100%

100%

100%

80%

100%

Chiropractic Care (Inpatient) Must be part of recovery treatment plan for acovered illness or injury
 Medical order or treatment plan required
Physical Therapy

 Not subject to coinsurance
 Maximum limit per visit: $75
 Medical order or treatment plan required
Occupational Therapy

 Not subject to coinsurance
 Maximum limit per visit: $75
 Medical order or treatment plan required
Extended Care Facility

PHYSICAL HEALTH

 Upon direct transfer from acute care facility
Home Nursing Care

 Provided by a home health care agency
 Upon direct transfer from an acute care facility
Transplant Lifetime maximum: $1,000,000
 Per period of coverage transplant maximum
limit: 1

 Organ procurement & harvesting costs lifetime
maximum: $10,000

 Travel & lodging lifetime maximum expense:$5,000 Covered transplants: cornea, heart, heart/lung,

lung, kidney, kidney/pancreas, liver, allogeneic or
autologous bone marrow Subject to the TRANSPLANT PRECERTIFICATION
provision and only when treatment is provided
within the Company’s approved independent
Managed Transplant System Network

Preventative CareNOT Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Maximum Limits per Calendar Year or, if indicated, per Lifetime

Benefit

Medical Concierge(Non-emergency)

In-Network

Out-of-Network

International

Not applicable

100%

100%

100%

Not applicable

100%

100%

100%

Adult Preventative Care Ages 19 and over
 Maximum limit: $500
 Refer to the PREVENTATIVE CARE provision forfurther details and requirements

Child Preventative Care Ages 18 and younger Maximum limit: $500
 Refer to the PREVENTATIVE CARE provision forfurther details and requirements

All coverage and benefits in the plan are in United States (U.S.) dollars. Benefits are subject to the exclusions and limitations and are payable only at Usual, Reasonable, and Customary
charges. This is a summary of a selection of plan benefits offered only as an illustration and does not supersede in anyway the Certificate of Insurance and governing policy
documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.

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Vision CareNOT Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Maximum Limits per Calendar Year or, if indicated, per Lifetime

Routine Eye Examination

Maximum limit every 24 months: $100

 Available after 12 months of continuous coverage
Corrective Lenses, Contacts, Frames

Maximum limit every 24 months: $150

 Available after 12 months of continuous coverage
Prescriptions

PHYSICAL HEALTH

Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Maximum Limits per Calendar Year or, if indicated, per Lifetime

United States Retail Pharmacy
Not subject to deductible and coinsurance
Copayments are per 30-day supply
Dispensing maximum: 90 days per prescription
Prescriptions $3,000 and higher will require
Universal RX (URX) to obtain prior authorizationfrom the Company






Universal RX (URX) Prescription Drug Card MUST be utilized for all outpatient prescription drugs in
the United States.
Retail Pharmacy Copayments:
Generic
Higher-cost generic and brandNon-preferred brand name

$5
$15
$30

Coinsurance: 100%
Subject to deductible and coinsurance
Dispensing maximum: 90 days per prescription

International Prescriptions
 Prescriptions $3,000 and higher will require
Universal RX (URX) to obtain prior authorizationfrom the Company

Expatriate Prescription Services Program
Generic$5
Brand name$15
Copayments are per 30-day supply
Dispensing maximum: 180 days per prescription
Contact Information:
 Enroll via the provider’s website: www.expatps.com
Prescription Submission:
 Email (scan prescription): epsmanager@universalrx.com
 Fax: +1.540.777.7184
Questions/Concerns:
 Phone number: +1.540.777.1450
 Email: epsmanager@universalrx.com

MENTALWELLNESS

Mental or Nervous, Substance Abuse and Counseling
Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Maximum Limits per Calendar Year or, if indicated, per Lifetime

Medical Concierge(Non-emergency)

Benefit
Lifetime Maximum

Out-of-Network

International$20,000

Inpatient Mental or Nervous/Substance Abuse

100%

100%

80%

100%

Not applicable

100%

80%

100%

Outpatient Mental or Nervous/Substance Abuse Maximum limit per visit: $100
 Maximum visits: 52
CRISIS SUPPORTIn-Network

Emergency Services
NOT Subject to Deductible or Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Maximum Limits per Calendar Year or, if indicated, per Lifetime

Benefit

Medical Concierge(Non-emergency)

In-Network

Out-of-Network

International

Not applicable

100%

80%

100%

Emergency Local Ambulance Subject to deductible and coinsurance Injury Illness resulting in an inpatient hospital admission

All coverage and benefits in the plan are in United States (U.S.) dollars. Benefits are subject to the exclusions and limitations and are payable only at Usual, Reasonable, and Customary
charges. This is a summary of a selection of plan benefits offered only as an illustration and does not supersede in anyway the Certificate of Insurance and governing policy documents(together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.

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S M( I M M I )Emergency Services
NOT Subject to Deductible or Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Maximum Limits per Calendar Year or, if indicated, per Lifetime

Benefit

Medical Concierge(Non-emergency)

In-Network

Out-of-Network

International

Not applicable

100%

100%

100%

Not applicable

100%

100%

100%

Not applicable

100%

100%

100%

Not applicable

100%

100%

100%

CRISIS SUPPORTEmergency Medical Evacuation

 Lifetime maximum: $1,000,000
 Insured persons under 65 years of age
 Approved in advance and coordinated by theCompany
Emergency Reunion Lifetime maximum: $10,000
 Maximum days: 15
 Maximum meal limit per day: $25
 Reasonable and necessary travel costs andaccommodations
 Approved in advance by the Company
Interfacility Ambulance Transfer
 Transfer must be a result of an inpatient hospital
admission
Return of Mortal Remains
 Maximum limit: $25,000
 Local burial/cremation maximum limit: $10,000
 Return of insured person’s mortal remains to home
Country Approved in advance by the Company

FINANCIALPROTECTION

Other Services
NOT Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Maximum Limits per Calendar Year or, if indicated, per Lifetime

Accommodation Benefit

 Maximum limit: $2,500
 Refer to the ACCOMMODATION BENEFIT provision
for further details
Crew Member Return Maximum limit: $2,500
Amateur Sailboat Racing Subject to deductible and coinsurance
Emergency Dental
 Subject to deductible and coinsurance Accident related

Not applicable

100%

100%

100%

Not applicable

100%

100%

100%

Not applicable

100%

80%

100%

Not applicable

80%

80%

100%

MENTALWELLNESSPHYSICAL HEALTH

Teleconsultation**

Company pays 100%

Traumatic Dental Injury

 Treatment at a hospital facility due to an accident
 Additional treatment for the same injury rendered

Not applicable

100%

80%

100%

by a dental provider will be paid at 100%

Hospital Indemnity

 International only Benefit is not available when the inpatient

hospital treatment is part of the Medical Travel
Management benefit Inpatient hospitalization only

 Overnight maximum limit: $100
 Maximum overnight limit: 20
 Maximum limit: $2,000

Remote Mental Health Service*

Company pays 100%

 Employee Assistance Program*Coverage for Remote Mental Health Service is not a determination that any specific condition discussed, raised, or identified during such consultation is covered under this insurance. The
Company reserves the right to decline future claims relating to or arising from any condition discussed, raised, or identified during a consultation where the illness or injury is directly or
indirectly related to any pre-existing condition or is otherwise excluded under this Certificate of Insurance.
**Teleconsultation will not support a diagnosis for Mental or Nervous disorders. Coverage for a Teleconsultation is not a determination that any specific condition discussed, raised, or
identified during such consultation is covered under this insurance. The Company reserves the right to decline future claims relating to or arising from any condition discussed, raised, or
identified during a Teleconsultation where the illness or injury is directly or indirectly related to any pre-existing condition or is otherwise excluded under this Certificate of Insurance.
All coverage and benefits in the plan are in United States (U.S.) dollars. Benefits are subject to the exclusions and limitations and are payable only at Usual, Reasonable, and Customary
charges. This is a summary of a selection of plan benefits offered only as an illustration and does not supersede in anyway the Certificate of Insurance and governing policy
documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.
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Other Services (continued)
FINANCIAL PROTECTIONNOT Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Maximum Limits per Calendar Year or, if indicated, per Lifetime

Medical Concierge(Non-emergency)

Benefit

Medical Travel Management

 Must be approved in advance by the Company

Supplemental Accident Benefit

 Maximum limit per covered accident: $500
PHYSICAL HEALTH

Recreational Underwater Activities

 Subject to deductible and coinsurance

In-Network

Out-of-Network

International

Medically necessary non-emergency treatment, including hospitalization and surgery for approved
procedures; the Company will offer medical travel as a means to manage the costs.
If medical travel is approved, the Company will reimburse 10% of the cost savings, up to a maximumof $7,500 back to the insured person where such savings arise from treatment outside of the U.S.
Meal allowance maximum: $100
Refer to the MEDICAL TRAVEL MANAGEMENT provision for further details and requirements.
Not applicable

100%

100%

100%

Not applicable

100%

80%

100%

Not applicable

100%

100%

100%

Non-emergency Medical Evacuation

 Lifetime maximum: $1,000,000
 Insured persons under age 65
 Approved in advance and coordinated by theCompany

P L A T I N U M Dental Benefits Summary
Coverage Limit/Maximum Amount for Eligible Dental Expenses
Calendar Year Maximum Limit$1,500 - $3,000

Calendar Year Orthodontia Maximum Limit$1,500 - $3,000

Deductible$50

 Applies to minor restorative, major restorative and orthodontia services
Family Deductible$150

 Maximum 3 deductibles per family

PHYSICAL HEALTH

Routine Services
NOT Subject to Deductible and Coinsurance unless otherwise noted
Eligible Expenses are limited to Usual, Reasonable, and Customary
Maximum Limits per Calendar Year or, if indicated, per Lifetime

BenefitCoinsurance

Diagnostic and Preventative Services

 Preventative visits and cleanings: 2(1 every 6 months)

 Radiographic examinations (including posterior bitewings): 2

Plan pays 100%

Insured pays 0%

Plan pays 100%

Insured pays 0%(1 every 6 months)

 Fluoride Treatment: 1 for children under age 19
Emergency Palliative Treatment

Minor Restorative
Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Maximum Limits per Calendar Year or, if indicated, per Lifetime

Radiographs

 Radiograph: 1 every 3 years
 Full mouth x-rays including panographic x-rays

Plan pays 80%

Insured pays 20%

Oral Surgery

Plan pays 80%

Insured pays 20%

Endodontics

Plan pays 80%

Insured pays 20%

All coverage and benefits in the plan are in United States (U.S.) dollars. Benefits are subject to the exclusions and limitations and are payable only at Usual, Reasonable, andCustomary charges. This is a summary of a selection of plan benefits offered only as an illustration and does not supersede in anyway the Certificate of Insurance and governing
policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.
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S M( I M M I )Periodontics

 Root planning: 1 every 2 years
 Periodontal surgery: 1 every 3 years

Plan pays 80%

Insured pays 20%

Plan pays 80%

Insured pays 20%

Minor Restorative Services

 Refer to the ELIGIBLE DENTAL EXPENSES provision for further details andrequirements

Major Restorative

PHYSICAL HEALTH

Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Maximum Limits per Calendar Year or, if indicated, per Lifetime

Major Restorative Services

 Crowns, jackets, inlays (on same tooth): 1 every 5 years
 Limitations apply for children under age 12
 Refer to the ELIGIBLE DENTAL EXPENSES provision for further details andPlan pays 50%

Insured pays 50%

Prosthodontics
 Dentures/bridges: 1 every 5 years
 Replacement of denture base material or reline: 1 every 3 years Refer to the ELIGIBLE DENTAL EXPENSES provision for further details andrequirements

Plan pays 50%

Insured pays 50%

requirements

Orthodontia Services
Subject to Deductible and Coinsurance unless otherwise noted
Eligible Medical Expenses are limited to Usual, Reasonable, and Customary
Maximum Limits per Calendar Year or, if indicated, per Lifetime

Orthodontia

Plan pays 50%

 Children under age 19

Insured pays 50%

Description of Services
Teleconsultation
 Online and telephonic access to a network of medical professionals available to diagnose, treat and prescribe for non-emergency medical issues. The best
medicine brought to you and your family 24 hours a day, seven days a week
Remote Mental Health Services
 Telemedicine for mental health that offers support with financial, physical, and emotional wellbeing. Whether you have questions about handling stress atwork or home, parenting and childcare, managing money or health issues, you can turn to this valuable benefit for a confidential service that you can trust.

Group Life Insurance (Optional)Group Life benefit includes:
 Term Life Insurance Benefit
 Accidental Death Benefit
 Dismemberment Benefit

Group Life can be issued as a flat amount(e.g., $50,000) or by salary (e.g., 2x salary)

10 or fewer employees:
 $10,000 minimum required
Automatically approved up to $100,000 if member is approved
for the IMMI medical plan
 Additional underwriting $100,001-$250,000

Group Life reduction schedule:
 Under age 65: full amount payable Ages 65-69: 35% reduction
 Ages 70-74: 55% reduction
 Ages 75-79: 70% reduction
 Age 80+: 80% reduction

International Marine Medical Insurance is a fully insured group benefit plan. The medical portion of the benefit plan is underwritten by Crum & Forster SPC, a member of theCrum & Forster Group of Companies and is available to members of the Fairmont Specialty Trust, LTD, c/o ITA Global Trust LTD, Camana Bay, Grand Cayman. **The Life portionof the benefit plan is underwritten by International Medical Insurance Group via Alstead Re, a segregated cell company distributed, managed and administered, as agent for
IMIG, by International Medical Group®, Inc. (IMG®).

All coverage and benefits in the plan are in United States (U.S.) dollars. Benefits are subject to the exclusions and limitations and are payable only at Usual, Reasonable, andCustomary charges. This is a summary of a selection of plan benefits offered only as an illustration and does not supersede in anyway the Certificate of Insurance and governing
policy documents (together the “Insurance Contract”). The Insurance Contract is the only source of the actual benefits provided.
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S M( I M M I )I M G P R O D U C E R U S E O N LY

HIRANO - HOLCOMB INSURANCE AGENCY, LLC
P.O. BOX 12580
MILL CREEK, WA 98082
Phone: 206-755-5585
Fax: 888-391-5155
masako@mhhinsurance.com
http://www.mhhinsurance.com

Telephone: +1.317.655.4500
Fax: +1.317.655.4505
Email: insurance@imglobal.com

W W W. I M G LO B A L . C O M
CM0050A2236231129

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