Confirmation of Coverage August 01, 2019 RE: Confirmation of Coverage for DEDAA AKOTO. ‘Certificate Number: PPLIUS2270177 To Whom It May Concern: < > roa L = a Please be advised that DEDAA AKOTOhas purchased Patriot Platinum Intemational{SM) certificate nurnber PPLIIS2270177 effective 02-Aug-2019 to 77-Aug-20) ‘The policy is administered by International Medical Group®, Inc., and underwritten by Sirius International Insurance Corporation (publ) located at 113 96 Stockholm, ‘Sweden, Sirius hasan "A" (Excellent) rating from AM. Best Medical coverage is provided while traveling worldwide outside of the insured person's Home Country ineluding Nicaragua. per policy provisions, Coverage includes the Schengsn states per the policy provisions. Emergency ‘evacuation (also known as Repatriation) is provided up to 4 muximum beset of $000,000.00 USD and Retum of Mortal Remains benetits up to a maximum of 100,000.00 USD are included when coordinated by IMG. .A copy of the Schedule of Benefits, wbich provides an outline of the plan’s coverage, limitations, and maximum benefits, as well as a copy of the Declaration page of the Certificate indicated above may be presented as required. This information will verify that Eligible Expenses, including Hospitalization and certain outpatient expenses, are subject toa 25000 USD annval deductible. Eligible Expenses are also subject to the following coinsurance provisions: For ligible Expenses up to the maximum limit. For treatment received within the U.S. and in the PPO Network, the plan pays 100% of Eligible Expenses up treatment received outside of the U-S.or Canada, the plan pays 100% of ‘to the maximum imit, For treatment received within the U.S, or Canada but outside of the PPO Network. the plan pays 90% of Eligible Expenses up to $5,000, then 100% up to the maxisvum limit. The maximum limit of coversge [per periad of insurance is 3,000,000.00 USD. Ifyou need further information, please feel free to contact our office at the number listed below. Thank you. ‘Sincerely, ‘Certificate Holder Services 317.655.4500 ‘Your Pratucer Comact information: Interatsaat Medes Group - 192036 2HON Meri St Iediamspots IN 44308 Telephone: 1866 36837261 397.655 9799, En: inueancedtiglatal ces Webse; —— aaxncimglobalom Tterastionnt Meseat Growpi 2960 Nath Meridian Suet Indunapos, IN 46208-4715 USA Telophooe: 13176354800 0 LSORAIEASGL Fax 1 317.635.4505 Woda ‘aoatancesiimgiobal com ven imgbal co,