GREEN COVER SM. Affordable and Complete Health Insurance Long-term protection for non-u.s. citizens between years of age

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1 GREEN COVER SM Affordable and Complete Health Insurance Long-term protection for non-u.s. citizens between years of age

2 AFFORDABLE AND COMPLETE HEALTH INSURANCE Green Cover provides 364 days of coverage for non-u.s. citizens between 60 and 95 years of age. A GREAT OPTION FOR YOU A great coverage option while waiting to qualify for Medicare. You can buy Green Cover if you have been in the United States for less than five years. Quick application process Receive a copy of your policy and virtual ID card via in as little as two business days. 364 days of coverage with low monthly payments if you need coverage for more than 364 days, you may apply for and buy a new policy when your prior one ends. You may stay in the U.S. the entire time you are covered. There s no requirement to leave during your policy period. YOUR BENEFITS Green Cover offers several plan options in an easy-to-understand format. You may choose Part A, Part B, or both. Part A Hospitalization Benefits include: Semi-private room & board, general nursing, miscellaneous hospital services & supplies, drugs, x-rays, lab tests, and operating room expenses. Treatment is covered at these facilities: Hospitals standard hospitalization and emergency treatment Hospice Facilities both inpatient and outpatient Skilled Nursing Facilities 30 day limit per period of coverage 1. Must follow a hospital confinement of 3 or more days 2. Admission must be within 30 days of hospital confinement Home Health Care Services - 30 days limit per period of coverage Physician and Surgeon Benefits Inpatient and Outpatient Care Supplies, Therapy and Ambulance Services Part B Included With Either A or B International Travel Coverage (automatically included) Coverage that follows you anywhere outside of the United States, so you re protected no matter where you go. If you are years of age, you have a $5,000 limit of protection. If you are years, your limit is $2,500. SPECIALIZED BENEFITS Protection For Coverage Amount Alzheimer s Disease $25,000 Lifetime Maximum Cardiac / Cancer $25,000* Cataract Surgery $2,000 Dental (Accidental) $500 Per Accident Skilled Nursing Facilities (Part A benefit) 30 Days - Per Policy Period Home Health Care (Part A benefit) 30 Days - Per Policy Period * After 180 days coverage, benefits are paid up to your policy maximum. POLICY MAXIMUM The maximum for your policy is determined by your age. Ages $250,000 Ages $100,000 Ages $50,000 Ages $25,000

MONTHLY PREMIUMS Parts A & B Combined AGE DEDUCTIBLE $1,000 $1,500 $2,500 $5,000 $10,000 60 $360 $310 $254 $209 $199 61 $367 $316 $263 $213 $205 62 $371 $326 $266 $218 $207 63 $378 $329 $273 $222

3 MONTHLY PREMIUMS Parts A & B Combined AGE DEDUCTIBLE $1,000 $1,500 $2,500 $5,000 $10, $360 $310 $254 $209 $ $367 $316 $263 $213 $ $371 $326 $266 $218 $ $378 $329 $273 $222 $ $384 $339 $282 $227 $ $390 $341 $287 $235 $ $407 $354 $297 $241 $ $425 $367 $305 $251 $ $443 $384 $312 $261 $ $459 $399 $321 $266 $ $478 $416 $329 $274 $ $495 $425 $342 $288 $ $515 $444 $360 $297 $ $533 $456 $370 $307 $ $547 $466 $387 $320 $ $484 $400 $328 $ $500 $416 $340 $ $510 $425 $350 $ $525 $441 $358 $ $540 $453 $369 $ $470 $376 $ $496 $415 $ $520 $460 $ $547 $505 $ $567 $546 $ $590 $ $633 $ $676 $ $716 $ $759 $ $ $ $ $ $ $831 Our Money Back Guarantee If you purchase Green Cover and decide you don t need it, simply notify Seven Corners before your coverage start date to receive a full refund. DEDUCTIBLE AND COINSURANCE There are five deductible options $1,000, $1,500, $2,500, $5,000 and $10,000 choose the best option available for you. You are responsible for your deductible first and then for your share of the coinsurance. After the deductible, we pay 80% of the next $10,000 in expenses, and you pay 20%. Green Cover then pays 100% of any remaining expense up to your policy maximum. QUICK APPLICATION PROCESS After you submit your application, Seven Corners will notify you within as little as two business days if you are approved for coverage. If you are approved, we will send you a copy of your policy and virtual ID card via with detailed contact information, just in case you need to contact us. Your coverage begins on the latter of: the day you request, the day we receive your payment and application, the day we approve your application. Your ID card will state your coverage period (start and end date). GET AFFORDABLE HEALTHCARE WITH EASY MONTHLY PAYMENTS!

4 YOUR INSURANCE COMPANY Your policy is backed by Certain Underwriters at Lloyd s, London, rated A (Excellent) by AM Best, so you know your coverage will be there when you need it. YOUR POLICY ADMINISTRATOR Seven Corners* will handle all of your policy needs from start to finish. Since 1993, we have been providing insurance products and servicing the needs of hundreds of thousands of policyholders worldwide. We are here to help! Our multilingual Seven Corners Assist team is available 24/7 to answer your questions. *In California, Seven Corners operates under the name Seven Corners Insurance Services. OUR EXTENSIVE PROVIDER NETWORK We have a large network of providers within the United States and worldwide. You can contact Seven Corners Assist for help finding a medical provider. This list is also available online at PRE-CERTIFICATION REQUIREMENTS You must pre-certify the following expenses by contacting Seven Corners Assist at the phone number on your ID card: Inpatient Care; any Surgery or Surgical Procedure; CAT scan and/or MRI (magnetic resonance imaging). If you have an emergency hospital admission, you must pre-certify within 48 hours of your admission or as soon as reasonably possible. Failure to pre-certify could result in a 50% reduction in benefits. Pre-certification does not guarantee benefits. WHAT ARE PRE-EXISTING CONDITIONS? Pre-existing conditions are any medical condition that existed when you applied for Green Cover or any time during the 12 months before your coverage start date. Green Cover does not cover pre-existing conditions. For a detailed explanation, please review the policy. EXCLUSIONS Below is a summary of items that are not covered. For a specific listing of items, please review your policy. Pre-existing conditions; Treatment of the following during the first 180 days of coverage: conditions of the breast, prostate, or reproductive system; gallstones, kidney stones, acne or acne related conditions, any surgery which is not emergency in nature; Treatment which is not medically necessary; elective surgery, cosmetic or plastic surgery (except as the result of a covered accident), treatment exceeding reasonable & customary charges, vocational, occupational, speech, recreational, music therapy, expenses due to or in connection with a felony or criminal offense; chronic fatigue syndrome, congenital abnormalities & related conditions; expenses related to a self-inflicted injury or illness; treatment related to alcohol usage, drug addiction, use of any drug or narcotic agent; injury or illness due to being under the influence of alcohol, chemicals or drugs other than drugs taken as prescribed by a physician; injury or illness due to operation of a vehicle after consuming alcohol, chemicals, or drugs; allergies; mental and nervous disorders, rest cures, quarantine or isolation; dental care (unless the result of an injury to a sound natural tooth caused by an accident); eye refractions; eye examinations done to prescribe corrective lenses for eyeglasses; false teeth or dentures; normal ear tests; hearing aids; vaccinations; inoculations; routine physicals; expenses resulting from subjective pain; coverage outside the United States unless covered under the International Travel Coverage Benefit; expense covered by Medicare or any other private or public program; expenses incurred after you are eligible for Medicare; expenses incurred after you become a U.S. citizen; purchase or rental of durable medical equipment outside of a hospital; outpatient drugs; injury due to participation in professional athletics, amateur, and interscholastic athletics. Injury sustained while participating in mountaineering, hang gliding, parachuting, bungee jumping, zip lining, racing of any kind, snowmobiling, motorcycle/motor scooter riding, scuba diving involving underwater breathing apparatus (unless PADI or NAUI certified), water skiing, snow skiing, snowboarding, luge, paragliding, motocross, Moto X, any sport or athletic activity undertaken for thrill seeking which exposes you to abnormal or extreme risk of injury &/or is in violation of applicable laws, rule, or regulations; Any consequence, whether directly or indirectly, proximately or remotely occasioned by, contributed to by, or traceable to, or arising in connection with war, invasion, act of foreign enemy, warlike operations (whether war be declared or not), civil war or commotion; riot; rebellion; insurrection; revolution; overthrow of the legal government; explosions of war weapons, usage of nuclear, chemical, biological weapons; terrorist activity. Coverage is not available in Maryland or Washington.

5 GREEN COVER SM APPLICATION To be eligible for Green Cover, you must not be eligible for Medicare. If you have been a legal resident of the United States for five years, you are eligible to purchase Medicare, and you should not complete this application. This plan is not available for U.S. citizens. If you become a U.S. citizen, this coverage will automatically terminate. Directions for Completing the Application 1. Please print or type all information. Illegible information will delay underwriting and processing of your coverage. 2. All questions on the application apply to the applicant requesting coverage. 3. Each applicant requires their own application; coverage cannot be issued for multiple people on the same certificate. Section 1: Coverage Details Requested coverage start date: / / (MM/DD/YYYY) (must be within 30 days of application date) If accepted, official effective date will be advised by Seven Corners. Deductible Amount: $1,000 $1,500 $2,500 $5,000 $10,000 Ages 60 to 74 choose any deductible option Ages 85 to 89 - choose $5,000 or $10,000 Ages 75 to 79 - choose $1,500; $2,500; $5,000; or $10,000 Ages 90 to 95 - choose $10,000 Ages 80 to 84 choose $2,500; $5,000; or $10,000 Coverage Type: Part A & B Part A Only (Multiply Monthly Rate x.60) Part B Only (Multiply Monthly Rate x.60) *After you make your selection, please keep in mind that you may not alter your coverage type. Section 2: Applicant Information Applicant s Name (Last, First) Gender Date of Birth (MM/DD/YYYY) Height (Feet/Inches) Weight (Pounds) Monthly Rate Residence Address: Apartment #: City: State: Postal Code: Telephone ( ) - Fax: ( ) - Are you a U.S. citizen? How long have you been a U.S. resident as of today? Date you expect to be eligible for Medicare: / / (MM/DD/YYYY) Section 3: Medical History Last healthcare provider visit: a. Date and reason of last visit: b. Results of last visit: In order for your application to be processed successfully, each question must be answered truthfully. If yes is answered, please provide full details in the area provided below or attach a separate page. 1. Do you intend to engage in sports or any other pastimes that expose you to extra personal injury? 2. Have you ever been declined or accepted on special terms for life, accident or illness insurance? 3. Have you ever had any abnormal tests or blood work that have required additional evaluation or treatment?

6 4. Have you ever been evaluated or treated for any injury, condition or disorder involving the following? a. Eyes/Ears o. Back/Spine/Neck b. Gout p. Throat/Thyroid/Glands c. Skin q. Bones/Bone Density d. Hernias e. Diabetes f. HIV/AIDS g. Sleep Apnea r. Arthritis/Joints (Hips, Knees, Shoulders) s. Fainting / Dizziness / Unconsciousness t. Fatigue / Tiredness/ Paralysis / Weakness u. Nervous System / Alzheimer s / Dementia h. Gall Bladder v. Mental/Emotional/Psychiatric i. Concussions w. Respiratory System/Asthma j. Chronic Pain x. Circulatory System k. Lymph des y. Reproductive System l. Cancer/Growth z. Gastrointestinal System m. High Blood Pressure aa. Urinary System/Prostate n. Heart/Chest Pain/Stroke ab. Any other condition not listed above 5. In the past 12 months, have you experienced a weight gain or loss of 15 pounds or more? 6. Have you ever undergone a surgical operation? 7. Have you taken any medicines in the past 12 months? If yes, include conditions in details below. 8. Have you ever been recommended to have any procedure(s), exam(s), treatment(s), and/or test(s) that have not been completed? 9. Have you recently experienced any signs, indications, symptoms, diagnosis or treatment that would cause you to believe that you currently have a new medical condition? 10. Do you need any assistance to perform activities of daily living (feeding, bathing, dressing)? Question # Condition/Diagnosis, Treatment, Medications Prescribed and Results of Treatment Duration/Dates of Treatment If additional space is needed, please attach a separate page Section 4: Declaration I hereby apply for the Green Cover program and for the insurance provided by Certain Underwriters at Lloyd s, London (the Underwriter ) for which I hereby subscribe to the World Commercial Trust and enroll in the group coverage for which I am eligible under the group contract issued by Certain Underwriters at Lloyd s, London. I represent that I have read the completed application and that all my answers and statements on this Application and any attachments hereto are complete and true to the best of my knowledge and belief. I understand that my qualification for insurance is based upon my answers and statements herein and that this information may be verified by Seven Corners, Inc. (the Administrator ). I understand that no one has the authority to exclude or direct me to exclude any information sought by this form. I understand that the Administrator will rely on all information on this Application in determining whether or not to issue coverage and that any incorrect or incomplete information may result in a claim denial or loss of coverage.

7 I understand that benefits may be limited or excluded for conditions for which any insured person has received any medical diagnosis or treatment, or taken any medication, or realized the manifestation of a condition, or for a condition that with reasonable medical certainty existed before his or her effective date, according to the pre-existing conditions provisions of the plan. I authorize any physician, medical practitioner, hospital, clinic, other medical or medically-related facility, the Medical Information Bureau, Inc. (MIB, Inc.), consumer reporting agency, insurance or reinsuring company, or employer having certain information about me or my dependents to give Seven Corners, Inc. or its legal representative, any and all such information. The nature of the information authorized to be disclosed includes, but is not limited to, information about: physical condition(s), health history(ies), avocation(s), age(s), occupation(s), and personal characteristic(s). This authorization includes information about drugs, alcohol, mental illness, or communicable diseases. I understand the information obtained by use of this Authorization will be used by the Administrator to determine eligibility for benefits. I also authorize the Administrator to release any information obtained to reinsuring companies, the Medical Information Bureau, Inc., or other persons or organizations performing business or legal services in connection with my application, claim, or as may be otherwise lawfully required, or as I may further authorize. I understand that as a resident of a foreign jurisdiction, I may be subject to foreign laws with respect to the type and form of coverage in which I am enrolling. I also understand and agree that responsibility for complying with those foreign laws rests solely on me. I understand that no coverage is effective until I am notified in writing by the Administrator and advised of the official Effective Date. I also understand that if I am not accepted for coverage by the Administrator, the sole obligation of the Administrator and the Underwriter is to return the premium. I also understand that Certain Underwriters at Lloyd s, London operates as a surplus lines insurer in most U.S. states. Claims may not be made against a state guarantee insurance fund. I understand and agree that this program is issued outside the United States, and the coverage may not comply with the minimum requirements set forth by any law or regulation within or outside the United States. I understand that this program is not, nor does it intend to be, a general United States health insurance policy. This insurance is not subject to and does not provide certain insurance benefits required by the United States Patient Protection and Affordable Care Act ( PPACA ). The insurance benefits provided by this policy are stated in your policy documents and do not include any additional benefits required by the PPACA. The PPACA requires certain U.S. residents and citizens to obtain PPACA compliant insurance coverage. In certain circumstances, penalties may be imposed on U.S. residents and citizens who do not maintain PPACA compliant insurance coverage. You should consult your attorney, insurance agent, or tax professional to determine if the PPACA s requirements are applicable to you. I also understand any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an enrollment form, or files a claim containing a false or deceptive statement may be guilty of insurance fraud. Signature of Proposed Insured Date I would like to receive communications from Seven Corners and/or my agent about products in the future.

8 Section 5: Method of Payment Visa MasterCard Discover /vus American Express Card Number: Expiration Date: / (mm/yyyy) Name as it appears on the card: Daytime Phone ( ) - Alternate Phone Number: ( ) - Billing Address: City: State: Postal Code: All premium payments must be made in U.S. dollars. This authorization will remain in effect until revoked by me in writing and until Seven Corners actually receives notice. Coverage purchased by credit/debit card is subject to validation and acceptance by the credit/debit card company. I pre-authorize Seven Corners to debit my credit/debit card for the proper installment amount on the due date of the installment. All payments must be submitted at the time application for coverage is made. Signature (Required): Section 6: Agent Information Agent Name: _ Seven Corners Agent #: _ Address: _ City: State: Postal Code: Agent Certification: I am not aware of any other information that may have a bearing on the insurability of anyone to be covered and have not altered any responses recorded on this application nor any supplement to the application. I have not advised the Applicant to withhold any information regarding the answers to the questions and have advised the Applicant to review the application and the answers recorded to confirm completeness and accuracy. Signature of Agent Date Please mail, fax, or completed application to: orders@globalhealthinsurance.com

9 IMPORTANT INFORMATION IMPORTANT INFORMATION REGARDING YOUR COVERAGE Please be aware that this is not a general health insurance policy, but an interim, limited benefit period program. This brochure is intended as a brief summary of benefits and services. It is not your policy. If there is any difference between this brochure and your policy, the provisions of the policy will prevail. Benefits and premiums are subject to change. Patient Protection and Affordable Care Act: This insurance is not subject to, and does not provide certain insurance benefits required by the United States Patient Protection and Affordable Care Act ( PPACA ). The insurance benefits provided by this policy are stated in your policy documents and do not include additional benefits required by PPACA. The PPACA requires certain U.S. residents and citizens to obtain PPACA compliant insurance coverage. In certain circumstances penalties may be imposed on U.S. residents and citizens who do not maintain PPACA compliant insurance coverage. You should consult your attorney, insurance agent or tax professional to determine if the PPACA s requirements are applicable to you. ADMINISTERED BY FOR ADDITIONAL INFORMATION 303 Congressional Boulevard Carmel, IN Fax: by Seven Corners, Inc. Seven Corners is a registered trademark of Seven Corners, Inc. v

COVER. Affordable and Complete Health Insurance Coverage in the U.S. for non-u.s. citizens who are 60 to 95 years of age

COVER. Affordable and Complete Health Insurance Coverage in the U.S. for non-u.s. citizens who are 60 to 95 years of age GREEN COVER Affordable and Complete Health Insurance Coverage in the U.S. for non-u.s. citizens who are 60 to 95 years of age AFFORDABLE AND COMPLETE HEALTH INSURANCE Green Cover provides 5 to 364 days