Liability Package for Peace Corps
Personal Service Contractors
As you set off to provide assistance to Peace Corps efforts around the world, it is
necessary for you to maintain proper liability coverage should an unfortunate event
occur. Clements International is pleased to offer a complete worldwide liability
package designed specifically to meet the requirements of your contract at an
affordable price. Our packaged policy includes auto liability, personal liability,
personal accident and sickness coverage.
Auto Non-Ownership Liability
This portion of the package protects you if you are involved in acci-
dent while driving a government vehicle. It provides up to $50,000
coverage for Bodily Injury or Property Damage for which you might
be liable. If you are involved in an accident while driving a non-owned
vehicle overseas, you should immediately contact A.I.U., providing
full details of the accident.
Comprehensive Personal Liability
This coverage is designed to protect you in case someone brings suit
against you for personal actions overseas. If, for example, you acci-
dentally cause bodily harm to someone or unintentionally damage
their property, they may sue you for your negligence. This portion of
the package would provide up to $50,000 coverage in the event of
such an occurrence.
Personal Accident
If you are injured abroad and need medical attention, you could be
reimbursed for the actual expenses incurred as a result of this injury
up to $10,000 per occurrence. If you are killed by accident while over-
seas, your beneficiary will receive $20,000 under this portion of the
coverage. If you lose a limb or sight of one eye because of an acci-
dent, payment up to $10,000 will be made. The maximum benefit
payable for all losses due to one accident is $20,000.
Sickness Coverage
Sickness coverage is also provided under this portion of the package
for up to $10,000 per occurrence. If you become ill and require med-
ical attention, the first $25 of expense for any occurrence is to be
absorbed by you. The policy responds for the actual expenses above
this deductible up to the total expenditure of $10,000. If you are hos-
pitalized, the maximum benefit payable for room and board is $100
per day.
If you incur minor medical expenses above the deductible, you
should pay the bills and save the receipts to submit to the insurance
company along with your claims. You will then be reimbursed. If you
are hospitalized, you should obtain a bill from the hospital and pres-
ent it to A.I.U. with a claim form.
How much does it cost?
This package is affordably priced at $50 per month, with a two
month minimum. It is recommended that all contractors purchase
this policy for the entire length of their Peace Corps contract.
Who is Clements International?
Since 1947, Clements International has been providing innovative
insurance solutions to individuals and organizations operating outside
of their home country. Clements is also proud to be the administra-
tor of the CorpsCare program which provide post-service health ben-
efits to Volunteers and their families.
The Fine Print
1. There is no benefit payable for pre-existing conditions.
2. For Host Country Nationals, benefits are provided only during working hours as a
Peace Corps contractor.
3. Coverage is worldwide, excluding the United States
4. Should you have other medical insurance, such other insurance shall be consid-
ered Primary and any benefits payable there under shall not be payable under
this policy.
The description of insurance coverage in this brochure is a summary only. The cov-
erage is subject to the terms, conditions, limitations and exclusions contained in the
policy of insurance. In the event of any conflict between the outline of coverage
herein and the policy of insurance, the provisions contained in the policy of insur-
ance will govern
Apply online today.
You may apply online or complete and submit the application
on the back of this page.
Clements International
One Thomas Circle NW, 8th Floor
Washington DC 20005, USA
1.202.872.0060 or 1.800.872.0067
1.202.466.9064 fax
pc@clements.com
 PSC Liability Package Application
General Application

Client Status n New n Former n Current Date M______D______Y______

1. First Name____________________________ M.I.______ Last Name_____________________________________ Date of Birth M____D____Y____ Sex nM nF

2. Citizenship Occupation Personal Service Contractor Agency Peace Corps

3. Foreign Post Address___________________________________________________________________________________________________________________________

_______________________________________________ City_______________________________________ Country___________________________________________

4. How long do you anticipate staying at this location?___________________________ Date leaving for foreign post?_________________________________________

4. Permanent Home Country Address______________________________________________________________________________________________________________

5. Home Ph #_______________________ Work Ph #________________________ Mobile Ph #________________________ E-mail________________________________

Liability Package Application

I hereby apply for $50,000.00 Non-owned Automobile Liability Insurance, $50,000.00 Comprehensive Personal Liability, and $10,000.00 Personal Accident
Insurance (including $10,000.00 Medical Reimbursement for sickness) to satisfy the liability insurance requirements of your Peace Corps contract. I under-
stand that Clements International will immediately notify the Contracts office at the Peace Corps advising that I have purchased the necessary coverage for
the specified period.

1. I am scheduled to perform service overseas under a personal services contract in _______________________ (country).

2. My contract begins on M______D______Y______ (start date) and ends on M______D______Y______ (end date).

3. Drivers License #_______________________________________ State/Country of Issue__________________________________________

4. Name of Beneficiary____________________________________ Relationship to Applicant_________________________________________

Notice: Coverage cannot be made effective retroactively if this application is received after the contract date. Coverage will be made effective on the date

the application was received and processed. Applications must be submitted with full payment to be processed.

Liability Package Application Summary Policy Length (in Months) Total Premium

There is a two month minimum for all policies. It is recommended ______________________ x $50.00 $ _______________________________
that all contractors purchase this policy for the entire length of their
Peace Corps contract.

Payment Options Delivery Options

Payment by:
n Telecheck, pay by check instantly at pc.clements.com
Mail policies and renewal notices to (choose one):

n Check enclosed, payable to Clements International

n Yes, I want to be an e-customer. As an e-Customer all correspondence
E-Mail Address (E-Customer Option)

Credit Card n VISA n MasterCard n AMEX including renewal invoices and policies will be sent to the e-mail address
supplied above. You will need Adobe Acrobat Reader. You may download
Cardholder Name ______________________________________________________ a free copy of the software at www.adobe.com.
n Foreign Post Address n Permanent Home Country Address
Card No.

Exp. Date
M Y Amount $__________________________

Signature and Verification

My signature below certifies that all information I have provided on this appli- Submit Application and Payment to:
cation is true to the best of my knowledge. It further serves as authorization
if I have chosen to pay by credit card
Clements International
One Thomas Circle NW, 8TH Floor
Washington, D.C. 20005 USA
Credit Card holders can transmit applications and payment by fax
________________________________________________ ___________________ (202-466-9064), or on our website (pc.clements.com).
(X) Signature Date