STUDY ABROAD INSURANCE PLAN

World Class Coverage Plan designed for

Brandeis University
2019-2020

Policy # GLM N04965152

Administered by Cultural Insurance Services International • 1 High Ridge Park • Stamford, CT 06905-1322
This plan is underwritten by ACE American Insurance Company, a member of the Chubb Group of Companies

Question(s) or need assistance?

CISI Claims Department (9-5 EST, M-F): Phone: (800) 303-8120 ext. 5130 | (203) 399-5130 | E-mail: claimhelp@mycisi.com
Team Assist (24/7/365) – AXA Assistance: Phone: (855) 327-1411 | (312) 935-1703 | E-mail: medassist-usa@axa-assistance.us

What does the CISI plan cover?

The CISI Plan is designed specifically for cultural exchange participants. In addition to providing accident and sickness insurance, the plan will
cover medical evacuation and repatriation should they become necessary. And unlike many domestic insurance plans, the CISI plan will pay
100% of covered expenses without requiring a deductible.
In addition to the above, the Team Assist Plan was designed by CISI in conjunction with the Assistance Company to provide travelers with a
worldwide, 24-hour emergency telephone assistance service. Multilingual help and advice may be furnished for the insured in the event of any
emergency during the term of coverage. This plan complements the insurance benefits provided by the Brandeis University study abroad
medical plan.

Schedule of Benefits
Coverage and Services Maximum Limits

Accidental Death and Dismemberment Per Insured Person $10,000

Medical expenses (per Covered Accident or Sickness):

Deductible zero

Benefit Maximum $150,000 at 100%

Extension of Benefits 30 days

Emergency Medical Reunion $2,500

(incl. hotel/meals, max $200/day)

Team Assist Plan (TAP): 24/7 medical, travel, technical assistance

Emergency Medical Evacuation $250,000

Repatriation/Return of Mortal Remains $100,000

Policy terms and conditions are briefly outlined in this Description of Coverage. Complete provisions pertaining to this insurance are contained in the
Master Policy on file with Brandeis University under form number AH-15090. In the event of any conflict between this Description of Coverage and
the Master Policy, the Policy will govern.

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Eligibility and Provisions

Benefits are payable under the Policy for Covered Expenses incurred by an Insured Person for the items stated in the Schedule of Benefits.
All students and accompanying faculty and staff who are enrolled as Brandeis University study abroad participants, and who are
temporarily pursuing educational activities outside of the United States and their Home Country are eligible for coverage. Benefits shall
be payable to either the Insured Person or the Service Provider for Covered Expenses incurred Worldwide, except in the United States or
their Home Country. The first such expense must be incurred by an Insured Person within 30 days after the date of the Covered Accident
or commencement of the Sickness; and
• All expenses must be incurred by the Insured Person within 364 days from the date of the Covered Accident or commencement
of the Sickness; and
• The Insured Person must remain continuously insured under the Policy for the duration of the treatment.
The charges enumerated herein shall in no event include any amount of such charges which are in excess of Reasonable and Customary
charges. If the charge incurred is in excess of such average charge such excess amount shall not be recognized as a Covered Expense.
All charges shall be deemed to be incurred on the date such services or supplies, which give rise to the expense or charge, are rendered
or obtained.

Accidental Death and Dismemberment Benefit

Accidental Death Benefit. If Injury to the Insured Person results in death within 365 days of the date of the Covered Accident that

caused the Injury, We will pay 100% of the Benefit Amount.

Accidental Dismemberment Benefit. If Injury to the Insured Person results, within 365 days of the date of the Covered Accident that

caused the Injury, in any one of the Losses specified below, We will pay the percentage of the Benefit Amount shown below for that Loss:

For Loss of: Percentage of Maximum Amount:

Life 100%
Two or more Members 100%
Speech and Hearing in Both Ears 100%
One Member 50%
Speech or Hearing in Both Ears 50%
Hearing in One Ear 25%
Thumb and Index Finger of the Same Hand 25%

“Member” means Loss of Hand or Foot and Loss of Sight. “Loss of Hand or Foot” means complete Severance through or above the wrist
or ankle joint. “Loss of Sight” means the total, permanent Loss of Sight of one eye. “Loss of Speech” means total and permanent loss of
audible communication that is irrecoverable by natural, surgical or artificial means. “Loss of Hearing” means total and permanent Loss
of Hearing in an ear that is irrecoverable and cannot be corrected by any means. “Loss of a Thumb and Index Finger of the Same Hand”
means complete Severance through or above the metacarpophalangeal joints of the same hand (the joints between the fingers and the
hand). “Severance” means the complete separation and dismemberment of the part from the body. If more than one Loss is sustained
by an Insured Person as a result of the same Covered Accident, only one amount, the largest, will be paid. Maximum aggregate benefit
per occurrence is $1,000,000.

Accident and Sickness Medical Expenses

We will pay Covered Expenses due to Accident or Sickness only, as per the limits stated in the Schedule of Benefits. Coverage is limited to
Covered Expenses incurred subject to Exclusions. All bodily Injuries sustained in any one Covered Accident shall be considered one
Disablement, all bodily disorders existing simultaneously which are due to the same or related causes shall be considered one
Disablement. If a Disablement is due to causes which are the same or related to the cause of a prior Disablement (including complications
arising there from), the Disablement shall be considered a continuation of the prior Disablement and not a separate Disablement.
Treatment of an Injury or Sickness must occur within 30 days of the Accident or onset of the Sickness.
When a Covered Injury or Sickness is incurred by the Insured Person We will pay Reasonable and Customary medical expenses as stated
in the Schedule of Benefits. In no event shall Our maximum liability exceed the maximum stated in the Schedule of Benefits as to Covered
Expenses during any one period of individual coverage.

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Covered Accident and Sickness Medical Expenses

Only such expenses, incurred as the result of a covered Accident or Sickness, which are specifically enumerated in the following
list of charges, and which are not excluded in the Exclusions section, shall be considered as Covered Expenses:

• Charges made by a Hospital for room and board, floor nursing and other services inclusive of charges for professional service 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.

• Charges made for Intensive Care or Coronary Care charges and nursing services.
• Charges made for diagnosis, treatment and surgery by a Doctor.
• Charges made for an operating room.
• Charges made for outpatient treatment, same as any other treatment covered on an inpatient basis. This includes ambulatory
surgical centers, Doctors’ outpatient visits/examinations, clinic care, and surgical opinion consultations.

• Charges made for the cost and administration of anesthetics.

• 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.

• Dressings, drugs, and medicines that can only be obtained upon a written prescription of a Doctor or surgeon.
• Charges made for artificial limbs, eyes, larynx, and orthotic appliances, but not for replacement of such items.
• Local transportation to or from the nearest Hospital or to and from the nearest Hospital with facilities for required treatment. Such
transportation shall be by licensed ground ambulance only.

• Charges for physiotherapy, if recommended by a Doctor for the treatment of a specific Disablement and administered by a licensed
physiotherapist.
• Nervous or Mental Disorders are payable a) up to $2,500 for outpatient treatment; or b) up to $10,000 on an inpatient basis. We shall
not be liable for more than one such inpatient or outpatient occurrence under the Policy with respect to any one Insured Person.

• Chiropractic Care and Therapeutic Services shall be limited to a total of $50 per visit, excluding x-ray and evaluation charges, with a
maximum of 10 visits per Injury or Sickness. The overall maximum coverage per Injury or Sickness is $500 which includes x-ray and
evaluation charges.

• Accidental dental charges for emergency dental repair or replacement to natural teeth damaged as a result of a covered Injury
including expenses incurred for services or medications prescribed, performed or ordered by dentist.
• With respect to Palliative Dental, an eligible Dental condition shall mean emergency pain relief treatment to natural teeth up to $500
($250 maximum per tooth).

• Pregnancy, childbirth or miscarriage.

• Charges due to a Pre-Existing Condition are covered up to $2,500 on a primary basis. Any remaining costs are payable secondary to
any other insurance plan, up to the Medical Expense maximum.

• Therapeutic termination of pregnancy is covered up to a maximum of $500.

Extension of Benefits
Medical benefits are automatically extended 30 days after expiration of Insurance for conditions first diagnosed or treated during or
related to your overseas study program with Brandeis University. Benefits will cease at 12:00 a.m. on the 31st day following Termination
of Insurance. Benefits are only payable to the extent that Covered Expenses are not payable under any other domestic health care plan.

Emergency Medical Reunion

When an Insured Person is hospitalized for more than 6 consecutive days, We will reimburse for round trip economy-class transportation
for one individual selected by the Insured Person, from the Insured Person’s current Home Country to the location where the Insured
Person is hospitalized.

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We will also pay this benefit if the Insured Person was the victim of a Felonious Assault. “Felonious Assault” means a violent or criminal act
reported to the local authorities which was directed at the Insured Person during the course of, or an attempt of, a physical assault resulting
in serious Injury, kidnapping or rape.
The benefits reimbursable will include:
• The cost of a round trip economy airfare and their hotel and meals up to the maximum stated in the Schedule of Benefits, Emergency
Medical Reunion.

Exclusions and Limitations

For benefits listed under Accidental Death and Dismemberment, this insurance does not cover:
• Disease of any kind.
• Bacterial infections except pyogenic infections which occur from an accidental cut or wound.
• Neuroses, psychoneuroses, psychopathies, psychoses or mental or emotional diseases or disorders of any type.
• Intentionally self-inflicted Injury; suicide or attempted suicide (Applicable to Accidental Death and Dismemberment benefits only).
• War or any act of war, whether declared or not.
• Injury sustained while riding as a pilot, student pilot, operator, or crew member, in or on, boarding or alighting from, any type of
aircraft.
• Injury occasioned or occurring while committing or attempting to commit a felony, or to which the contributing cause was the
Insured Person being engaged in an illegal occupation.
In addition, this Insurance does not cover Medical Expense Benefits for:

• Charges for treatment which is not Medically Necessary.

• Charges for treatment which exceed Reasonable and Customary charges.
• Charges incurred for surgery or treatments which are experimental/investigational, or for research purposes.
• Services, supplies or treatment, including any period of Hospital confinement, which were not recommended, approved and
certified as Medically Necessary and reasonable by a Doctor.
• War or any act of war, whether declared or not.
• Injury sustained while participating in professional athletics.
• Routine physicals, immunizations, 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 an Injury or Sickness established by a prior call or
attendance of a Doctor.
• Treatment of the temporomandibular joint.
• Any treatment, service or supply not specifically covered by the Policy.
• Services or supplies performed or provided by a Relative of the Insured Person, or anyone who lives with the Insured Person.
• Cosmetic or plastic surgery, except as the result of a covered Injury.
• Elective Surgery or Elective Treatment which can be postponed until the Insured Person returns to his/her Home Country or
Permanent Residence, where the objective of the trip is to seek medical advice, treatment or surgery.
• Treatment and the provision of false teeth or dentures, normal hearing tests and the provision of hearing aids.
• Eye refractions or eye examinations for the purpose of prescribing corrective lenses for eye glasses or for the fitting thereof, unless
caused by an Injury incurred while insured hereunder.
• Treatment while confined primarily to receive custodial care, educational or rehabilitative care, or nursing services.
• Congenital abnormalities and conditions arising out of or resulting therefrom.
• Expenses as a result of or in connection with the commission of a felony offense.
• Injury sustained while taking part in mountaineering where ropes or guides are normally used; hang gliding; parachuting; bungee
jumping; racing by horse, motor vehicle or motorcycle; parasailing.
• Treatment paid for or furnished under any mandatory government program or facility set up for treatment without cost to any
individual.
• Injury or Sickness covered by Workers’ Compensation, Employers’ Liability laws, or similar occupational benefits.
• Injuries for which benefits are payable under any no-fault automobile insurance policy.
• Routine dental treatment.

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• Drugs, treatments or procedures that either promote or prevent conception, or prevent childbirth, including but not limited to:
artificial insemination, treatment for infertility or impotency, sterilization or reversal thereof, or abortion.
• Treatment for human organ tissue transplants and related treatment.
• Weak, strained or flat feet, corns, calluses, or toenails.
• Diagnosis and treatment of acne.
• 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.
• Dental care, except as the result of Injury to natural teeth caused by a Covered Accident, unless otherwise covered under this
Policy.
• Expenses incurred within the Insured Person’s Home Country or country of Permanent Residence, unless otherwise covered under
this Policy.

This insurance does not apply to the extent that trade or economic sanctions or other laws or regulations prohibit Us from providing
insurance, including, but not limited to, the payment of claims.

Subrogation
To the extent the Company pays for a loss suffered by an Insured Person, the Company will take over the rights and remedies the Insured
Person had relating to the loss. This is known as subrogation. The Insured Person must help the Company to preserve its rights against
those responsible for the loss. This may involve signing any papers and taking any other steps the Company may reasonably require. If
the Company takes over an Insured Person’s rights, the Insured Person must sign an appropriate subrogation form supplied by the
Company.

Definitions
Company shall be ACE American Insurance Company.

Covered Accident means an event, independent of Sickness or self-inflicted means, which is the direct cause of bodily Injury to an Insured Person.

Covered Expenses means expenses which are for Medically Necessary services, supplies, care, or treatment due to Sickness or Injury, prescribed,

performed or ordered by a Doctor, and Reasonable and Customary charges incurred while insured under this Policy, and that do not exceed the

maximum limits shown in the Schedule of Benefits, under each stated benefit.

Deductible means the amount of eligible Covered Expenses which are the responsibility of each Insured Person and must be paid by each Insured

Person before benefits under the Policy are payable by Us. The Deductible amount is stated in the Schedule of Benefits, under each stated benefit.

Dependent means an Insured’s lawful spouse or an Insured’s unmarried child, from the moment of birth through the earlier of their 26th birthday

or the day two (2) years following the loss of their dependent status according to federal tax rules. A child, for eligibility purposes, includes an

Insured’s: 1) natural child; 2) adopted child, beginning with any waiting period pending finalization of the child’s adoption; and 3) a stepchild who

resides with the Insured or depends on the Insured for financial support. Also, Dependent includes a newborn child of any Insured. Insurance

will continue for any Dependent child who reaches the age limit and continues to meet the following conditions: 1) the child is handicapped; 2)

the child is not capable of self-support; and 3) the child depends mainly on the Insured for support and maintenance.

The Insured must give Us proof that the child meets these conditions, when requested. We will not ask for proof more than once a year. If the

Insured has elected coverage for a Dependent child, any newly born child of the Insured will be covered from the moment of birth for 60 days.

Coverage may be continued beyond this time period if the Insured notifies Us within 60 days of the child’s birth and pays any required premium.

“Dependent” also means an Insured Person’s Domestic Partner. “Domestic Partner” means a person of the same or opposite sex of the Insured

Person who: 1) shares the Insured Person’s primary residence; 2) is financially interdependent with the Insured Person in each of the following

ways; a) by holding one or more credit or bank accounts, including a checking account, as joint owners; b) by owning or leasing their permanent

residence as joint tenants; c) by naming, or being named by the other as a beneficiary of life insurance or under a will; d) by each agreeing in

writing to assume financial responsibility for the welfare of the other. 3) has signed a Domestic Partner declaration with Insured Person, if

recognized by the laws of the state in which he or she resides with the Insured Person; 4) has not signed a Domestic Partner declaration with any

other person within the last 12 months; 5) is 18 years of age or older; 6) is not currently married to another person; 7) is not in a position as a

blood relative that would prohibit marriage.

Doctor as used in this Policy means a doctor of medicine or a doctor of osteopathy licensed to render medical services or perform surgery in

accordance with the laws of the jurisdiction where such professional services are performed.

Effective Date means the date the Insured Person’s coverage under the Policy begins. An Eligible Person will be insured on the latest of: 1) the

Policy Effective Date; 2) the date he or she is eligible; or 3) the date requested by the Participating Organization provided the required premium is

paid.

Elective Surgery or Elective Treatment means surgery or medical treatment which is not necessitated by a pathological or traumatic change in

the function or structure in any part of the body first occurring after the Insured Person’s effective date of coverage. Elective Surgery includes,

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but is not limited to, circumcision, tubal ligation, vasectomy, breast reduction, sexual reassignment surgery, and sub-mucous resection and/or
other surgical correction for deviated nasal septum, other than for necessary treatment of covered purulent sinusitis. Elective Surgery does not
apply to cosmetic surgery required to correct Injuries suffered in a Covered Accident. Elective Treatment includes, but is not limited to, treatment
for acne, nonmalignant warts and moles, weight reduction, infertility, and learning disabilities.
Eligible Benefits means benefits payable by Us to reimburse expenses that are for Medically Necessary services, supplies, care, or treatment due
to Sickness or Injury, prescribed, performed or ordered by a Doctor, and Reasonable and Customary charges incurred while insured under this
Policy; and which do not exceed the maximum limits shown in the Schedule of Benefits under each stated benefit.
Emergency means a medical condition manifesting itself by acute signs or symptoms which could reasonably result in placing the Insured Person’s
life or limb in danger if medical attention is not provided within 24 hours.
Family Member or Immediate Family Member means an Insured Person’s spouse, domestic partner, child, brother, sister, parent, grandparent,
or immediate in-law.
Home Country means the country where an Insured Person has his or her true, fixed and permanent home and principal establishment or the
United States. Coverage under this Policy is extended to U.S. citizens traveling to U.S. Territories.
Hospital as used in this Policy means, except as may otherwise be provided, a Hospital (other than an institution for the aged, chronically ill or
convalescent, resting or nursing homes) operated pursuant to law for the care and treatment of sick or Injured persons with organized facilities
for diagnosis and surgery and having 24-hour nursing service and medical supervision.
Injury wherever used in this Policy means bodily Injury caused solely and directly by violent, accidental, external, and visible means occurring
while this Policy is in force and resulting directly and independently of all other causes in a loss covered by this Policy.
Insured Person(s) means a person eligible for coverage under the Policy as defined in “Eligible Persons” who has applied for coverage and is
named on the application if any and for whom We have accepted premium. This may be the Primary Insured Person or Dependent(s), if eligible
for coverage under the policy and the required premium is paid.
Medically Necessary or Medical Necessity means services and supplies received while insured that are determined by Us to be: 1) appropriate
and necessary for the symptoms, diagnosis, or direct care and treatment of the Insured Person’s medical conditions; 2) within the standards the
organized medical community deems good medical practice for the Insured Person’s condition; 3) not primarily for the convenience of the Insured
Person, the Insured Person’s Doctor or another service provider or person; 4) not experimental/investigational or unproven, as recognized by the
organized medical community, or which are used for any type of research program or protocol; and 5) not excessive in scope, duration, or intensity
to provide safe, adequate, and appropriate treatment.
Mental and Nervous Disorder means a Sickness that is a mental, emotional or behavioral disorder.
Permanent Residence or Country of Residence means the country where an Insured Person has his or her true, fixed and permanent home
and principal establishment, and to which he or she has the intention of returning.
Pre-Existing Condition means an illness, disease, or other condition of the Insured Person that in the 6-months before the Insured Person’s
coverage became effective under the Policy: 1) first manifested itself, worsened, became acute, or exhibited symptoms that would have caused a
person to seek diagnosis, care, or treatment; or 2) required taking prescribed drugs or medicines, unless the condition for which the prescribed
drug or medicine is taken remains controlled without any change in the required prescription; or 3) was treated by a Doctor or treatment had
been recommended by a Doctor
Reasonable and Customary means the maximum amount that We determine is Reasonable and Customary for Covered Expenses the Insured
Person receives, up to but not to exceed charges actually billed. Our determination considers: 1) amounts charged by other service providers for
the same or similar service in the locality where received, considering the nature and severity of the bodily Injury or Sickness in connection with
which such services and supplies are received; 2) any usual medical circumstances requiring additional time, skill or experience; and 3) other
factors We determine are relevant, including but not limited to, a resource based relative value scale.
Relative means spouse, Domestic Partner, parent, sibling, child, grandparent, grandchild, step-parent, step-child, step-sibling, in-laws (parent,
son, daughter, brother and sister), aunt, uncle, niece, nephew, legal guardian, ward, or cousin of the Insured Person.
Sickness wherever used in this Policy means illness or disease of any kind contracted and commencing after the Effective Date of this Policy and
covered by this Policy.
Termination of Insurance means the Insured Person’s coverage will end on the earliest of the following date: 1) the Policy terminates; 2) the
Insured Person is no longer eligible; 3) of the last day of the Term of Coverage, requested by the Participating Organization, applicable to the
Insured Person; or 4) the period ends for which premium is paid.
Termination of the Policy will not affect Trip coverage, if premium for the Trip is paid prior to the actual start of the Trip.
U.S. Territories means lands that are directly overseen by the United States Federal Government. A list of these territories would include the

United States Virgin Islands, Guam, American Samoa, Northern Mariana Islands, and Puerto Rico.

We, Our, Us means the insurance company underwriting this insurance.

IMPORTANT NOTICE This information provides a brief description of the important

This policy provides travel insurance benefits for individuals traveling features of the insurance plan. It is not a contract of insurance.
outside of their home country. This policy does not constitute The terms and conditions of coverage are set forth in the policy
comprehensive health insurance coverage (often referred to as “major issued in the state in which the policy was delivered under form
medical coverage”) and does not satisfy a person’s individual number AH- 15090. Complete details may be found in the policy
obligation to secure the requirement of minimum essential coverage on file at your school’s office. The policy is subject to the laws of
under the Affordable Care Act (ACA). the state in which it was issued. Please keep this information as
For more information about the ACA, please refer to a reference.
www.HealthCare.gov

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Team Assist Plan (TAP)

The Team Assist Plan is designed by CISI in conjunction with the Assistance Company to provide travelers with a worldwide, 24-hour
emergency telephone assistance service. Multilingual help and advice may be furnished for the Insured Person in the event of any
emergency during the term of coverage. The Team Assist Plan complements the insurance benefits provided by the Accident and Sickness
Policy.

If you require Team Assist assistance, your ID number is your policy number. In the U.S., call (855)327-1411, worldwide call (01-312) 935-
1703 (collect calls accepted) or e-mail medassist-usa@axa-assistance.us.

Emergency Medical Transportation Services

The Team Assist Plan provides services and pays expenses up to the amount shown in the Schedule of Benefits for:
• Emergency Medical Evacuation

• Repatriation/Return of Mortal Remains

All services must be arranged through the Assistance Provider.

Emergency Medical Evacuation Benefit

The Company shall pay benefits for Covered Expenses incurred up to the maximum stated in the Schedule of Benefits, if any Injury or
Covered Sickness commencing during the Period of Coverage results in the Medically Necessary Emergency Medical Evacuation of the
Insured Person. The decision for an Emergency Medical Evacuation must be ordered by the Assistance Company in consultation with the
Insured Person’s local attending Doctor.
Emergency Medical Evacuation means: a) the Insured Person’s medical condition warrants immediate transportation from the place
where the Insured Person is located (due to inadequate medical facilities) to the nearest adequate medical facility where medical
treatment can be obtained; or b) after being treated at a local medical facility, the Insured Person’s medical condition warrants
transportation with a qualified medical attendant to his/her Home Country or Permanent Residence to obtain further medical treatment
or to recover; or c) both a) and b) above.
Covered Expenses are expenses, up to the maximum stated in the Schedule of Benefits, Emergency Medical Evacuation, for transportation,
medical services and medical supplies necessarily incurred in connection with Emergency Medical Evacuation of the Insured Person. All
transportation arrangements must be by the most direct and economical route.

Repatriation/Return of Mortal Remains or Cremation Benefit

The Company will pay the reasonable Covered Expenses incurred up to the maximum as stated in the Schedule of Benefits,
Repatriation/Return of Mortal Remains, to return the Insured Person’s remains to his/her then current Home Country or Permanent
Residence, if he or she dies. Covered Expenses include, but are not limited to, expenses for embalming, cremation, a minimally necessary
container appropriate for transportation, shipping costs and the necessary government authorizations, and Escort Services: expenses
for an Immediate Family Member or companion who is traveling with the Insured Person to join the Insured Person's body during the
repatriation to the Insured Person's place of residence.

Note: All Covered Expenses in connection with either Emergency Medical Evacuation or Return of Mortal Remains must be pre-
approved and authorized by an Assistance Company representative appointed by the Company.

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The TAP offers these services (These services are not insured benefits):

Medical Assistance
Medical Referral: Referrals will be provided for doctors, hospitals, clinics or any other medical service provider requested by the
Insured. Service is available 24 hours a day, worldwide.

Medical Monitoring: In the event the Insured is admitted to a foreign hospital, the AP will coordinate communication between the
Insured’s own doctor and the attending medical doctor or doctors. The AP will monitor the Insured’s progress and update the family or
the insurance company accordingly.

Prescription Drug Replacement/Shipment: Assistance will be provided in replacing lost, misplaced, or forgotten medication by
locating a supplier of the same medication or by arranging for shipment of the medication as soon as possible.

Emergency Message Transmittal: The AP will forward an emergency message to and from a family member, friend or medical
provider.

Coverage Verification/Payment Assistance for Medical Expenses: The AP will provide verification of the Insured’s medical
insurance coverage when necessary to gain admittance to foreign hospitals, and if requested, and approved by the Insured’s insurance
company, or with adequate credit guarantees as determined by the Insured, provide a guarantee of payment to the treating facility.

Travel Assistance
Obtaining Emergency Cash: The AP will advise how to obtain or to send emergency funds world-wide.

Traveler Check Replacement Assistance: The AP will assist in obtaining replacements for lost or stolen traveler checks from any
company, i.e., Visa, Master Card, Cooks, American Express, etc., worldwide.

Lost/Delayed Luggage Tracing: The AP will assist the Insured whose baggage is lost, stolen or delayed while traveling on a common
carrier. The AP will advise the Insured of the proper reporting procedures and will help travelers maintain contact with the appropriate
companies or authorities to help resolve the problem.

Replacement of Lost or Stolen Airline Ticket: One telephone call to the provided 800 number will activate the AP’s staff in obtaining
a replacement ticket.

Technical Assistance
Credit Card/Passport/Important Document Replacement: The AP will assist in the replacement of any lost or stolen important
document such as a credit card, passport, visa, medical record, etc. and have the documents delivered or picked up at the nearest
embassy or consulate.

Locating Legal Services: The AP will help the Insured contact a local attorney or the appropriate consular officer when an Insured is
arrested or detained, is in an automobile accident, or otherwise needs legal help. The AP will maintain communications with the Insured,
family, and business associates until legal counsel has been retained by or for the Insured.

Assistance in Posting Bond/Bail: The AP will arrange for the bail bondsman to contact the Insured or to visit at the jail if incarcerated.

Worldwide Inoculation Information: Information will be provided if requested by an Insured for all required inoculations relative to
the area of the world being visited as well as any other pertinent medical information.

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Claim Information
If you seek medical treatment for an Injury or Illness while abroad and pay out-of-pocket, you are eligible to submit a claim for
reimbursement. A Claim Form can be found on the last two pages, on the myCISI Participant Portal, and attached to the welcome e-mail.
Please follow the directions at the top of the Claim Form, and make sure to include any medical documentation you received during your
visit and receipts for the out-of-pocket expenses. For your reference, below is some helpful information on how to handle both minor
Injuries or Illnesses and more serious situations.

In the Case of a Minor Injury or Illness

„ We are happy to pay a foreign provider directly. Many foreign providers, however, prefer payment from the patient when
services are rendered. Insureds using this insurance should be prepared to pay for doctor visits for minor illnesses such
as a sore throat or a sinus infection, for example. However, even for a minor illness, if the overseas doctor is willing to bill
us directly, we are willing and able to pay them directly for covered medical expenses (this is always up to the provider).

„ CISI's billing address and claim help # is on each ID card and on the claim form which is part of the brochure. If medical
expenses are incurred while abroad, the claim form and scanned copies of the itemized paid bill(s) can be emailed to
claimhelp@mycisi.com.
„ Claims should be submitted for processing as soon as possible (and no later than one year after treatment was received,
if possible). Claims are typically processed within 15 business days provided CISI has all of the information needed for
reimbursement.

„ A case does not need to be opened in advance in order for us to pay a claim for covered expenses for minor injuries/illnesses.
Team Assist (our 24/7 assistance provider) can help provide referrals to doctors/hospitals if needed but insureds may visit
any provider they would like and eligible expenses will be covered at 100% (in other words, CISI does not have network
restrictions.

In the Case of a Serious Injury or Illness

„ In the event of a serious illness or injury requiring expensive treatment or hospitalization, our goal is to have the hospital
or facility bill us directly so that neither the program/sponsor/school nor the insured needs to provide payment.

• In these situations, the insured (or someone calling on his/her behalf) needs to open a medical file with AXA Assistance
(our 24/7 assistance provider) asking for help with this. In addition to being able to pay by check, CISI also has the
ability to wire transfer to foreign hospitals when necessary/requested.
„ AXA Assistance is also able to guarantee/make payments and has a network of local partners who can make payments on
behalf of our insured's when necessary (CISI then reimburses AXA Assistance).

„ AXA Assistance (our medical/travel/technical partner) and WorldAware (our security partner) are both 24/7 operations. To
keep things simple, the number to call for a medical/travel/technical issue is the same as for a security related issue. The
toll-free 800 and non-800 (when calling from overseas) numbers for AXA Assistance are provided below as well as on the ID
card and in the brochure under the claim form. On the claim form we list CISI's claim help line (203-399-5130) and e-mail
address (claimhelp@mycisi.com) which are answered from 9-5 EST M-F. AXA Assistance has 24/7 access to our enrollment
database and also has access to each group's coverage information.

„ If a benefit or claim related call or e-mail comes to AXA Assistance during our business hours it is usually transferred to us.
After hours and on weekends, AXA Assistance handles the communications and involves our Claims Operations Manager
as needed 24/7.

An Important Note about Medical Evacuations

Sometimes an insured’s medical condition requires a medical evacuation to obtain further medical treatment in the nearest
adequate location or back in the U.S. It is important for insureds to know that in order for medical evacuation costs to be covered
all approvals and arrangements must be made by AXA Assistance in conjunction with the attending physician. Anyone may
contact AXA Assistance (see information on the following page) to open a medical file if assistance is needed or if evacuation
may be a possibility.

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STUDY ABROAD INSURANCE PLAN

Contact Information
For questions regarding benefits or the claim submission process, please contact CISI by phone, e-mail or mail:

To reach a CISI Claims Representative (9-5 EST M-F):

Phone: (800) 303-8120 ext. 5130 (calling toll-free from within the US)

(203) 399-5130 (calling from outside of the US, collect calls accepted)

E-mail: claimhelp@mycisi.com

Mail: Cultural Insurance Services International (CISI)

One High Ridge Park

Stamford, CT 06905

In cases of medical related emergency please contact our 24/7 emergency assistance provider:

Team Assist Provider: AXA Assistance

Phone: (855) 327-1411 (calling toll-free from within the US)

(312) 935-1703 (calling from outside of the US, collect calls accepted)

E-mail: medassist-usa@axa-assistance.us

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 Cultural Insurance Services International – Claim Form
„ Program Name: Brandeis University
„ Policy Number: GLM N04965152
„ Participant ID Number (from the front of your insurance card):

Mailing Address: 1 High Ridge Park, Stamford, CT 06905 | E-mail: claimhelp@mycisi.com | Fax: (203) 399-5596
For claim submission questions, call (203) 399-5130, or e-mail claimhelp@mycisi.com

Instructions:
1. Fully complete and sign the medical claim form for each occurrence, indicating whether the Doctor/Hospital has been paid.
2. Attach itemized bills for all amounts being claimed. *We recommend you provide us with a copy and keep the originals for yourself.
3. Approved reimbursements will be paid to the provider of the service unless otherwise indicated.
4. Submit claim form and attachments via mail, e-mail, or by fax (provided above).
See next page for state specific disclaimers and claimant cooperation provision.

► NAME AND CONTACT INFORMATION OF THE INSURED

Name of the Insured: Date of Birth: / /

(month/day/year)
*Please indicate which is your home address: £ U.S. Address £ Address Abroad

U.S. Address:
street address apt/unit # city state zip code

Address Abroad:
E-mail Address: Phone Number:

► IF IN AN ACCIDENT

Date of Accident: / / Place of Accident: Date of Doctor/Hospital Visit: / /

Description/Details of Injury (attach additional notes if necessary):

► IF SICKNESS/ILLNESS
Description of Sickness/Illness (attach additional notes if necessary):

*Onset Date of Symptoms: / / *Date of Doctor/Hospital Visit: / /

Have you had this Sickness/Illness before? £ YES £ NO If yes, when was the last occurrence and/or doctor/hospital visit?

► REIMBURSEMENT
Have these doctor/hospital bills been paid by you? £ YES £ NO
If no, do you authorize payment to the provider of service for medical services claimed? £ YES £ NO
If yes, any eligible reimbursements will be made in U.S currency (USD) via check. If you would like your eligible reimbursement in another currency via
wire transfer, please contact CISI at 203-399-5130 or claimhelp@mycisi.com for instructions.

Please note if you are submitting a claim for prescription medication, you must submit the prescription receipt. This will include your name,
the name of the prescribing physician, name of the medication, dosage, date and amount billed. Cash register receipts will not be considered
for reimbursement.

► CONSENT TO RELEASE MEDICAL INFORMATION

I hereby authorize any insurance company, Hospital or Physician or other person who has attended or examined me, including those in my home
country to furnish to Cultural Insurance Services International or any of their duly appointed representatives, any and all information with respect to any
sickness/illness or injury, medical history, consultation, prescriptions or treatment, and copies of all hospital or medical reports. A photo static copy of
this authorization shall be considered as effective and valid as the original.
I certify that the information furnished by me in support of this claim is true and correct.

Name (please print):

Signature: Date:
Cultural Insurance Services International – Claim Form
Page 2
Claimant Cooperation Provision: Failure of a claimant to cooperate with Us in the administration of a claim may result in the termination of a claim.
Such cooperation includes, but is not limited to, providing any information or documents needed to determine whether benefits are payable or the
actual benefit amount due.
For residents of Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit, or who knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to restitution or confinement in prison, or any
combination thereof.
For residents of Arkansas, Louisiana, New Mexico: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit,
or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
For residents of District of Columbia: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer
or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially
related to a claim was provided by the applicant.
For residents of California: For your protection, California law requires the following to appear on this form: Any person who knowingly presents a
false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
For residents of Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the
purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any
insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder
or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from
insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.
For residents of Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an
application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
For residents of Kansas: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or
)
belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an
)
application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit
)
pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any
)
fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.
)
For residents of Kentucky: Any person who knowingly and with intent to defraud any Insurance Company or other person files an application for
)
insurance containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto,
)
commits a fraudulent insurance act, which is crime.
)
For residents of Rhode Island: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
)
false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
)
For residents of Maine, Tennessee, Virginia, Washington: It is a crime to knowingly provide false, incomplete or misleading information to an
)
Insurance Company for the purpose of defrauding the Company. Penalties include imprisonment, fines and denial of insurance benefits.
)
For residents of Maryland: Any Person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit, or knowingly
)
and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
)
For residents of New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to

criminal and civil penalties.

)
For residents of New York: Any person who knowingly and with intent to defraud any Insurance Company or other person files an application for
)
insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact

material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars

and the stated value of the claim for each such violation.
)
For residents of Ohio: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or
)
files a claim containing a false or deceptive statement is guilty of insurance fraud.
)
For residents of Oklahoma: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds
)
of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
)
For residents of Oregon: Any person who knowingly, and with intent to defraud any insurance company or other persons files an application for
)
insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact
)
material thereto, may be subject to prosecution for insurance fraud.
)
For residents of Pennsylvania: Any person who knowingly and with the intent to defraud any Insurance Company or other person files an
)
application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information

concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
)
For claimants not residing in Alabama, Arkansas California, Colorado, District of Columbia, Florida, Kansas, Kentucky, Louisiana, Maine,
Maryland, New Jersey, New Mexico, New York, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, Tennessee, Virginia nor Washington:
Any person who, knowingly presents a false or fraudulent claim for payment of loss or benefit or knowingly presents false information in an application
for insurance is guilty of a crime and may be subject to fines and confinement in prison.