WorldTrips

251 North Illinois Street, Suite 600, Indianapolis, IN, 46204 USA
Tel: 317-262-2132 Fax: 317-262-2140 Toll Free: 800-605-2282
orders@worldtrips.com
worldtrips.com

Deep Chetanbhai Shukla InternationalStudentInsurance.com

Omkar,1-Bhaktinagar Society, http://www.internationalstudentinsurance.com
Near Kanta Stri Vikas Gruh 877-758-4391
Rajkot, 360002 info@internationalstudentinsurance.com
India

StudentSecure®
THANK YOU!
IMPORTANT
Thank you for purchasing a StudentSecure insurance plan.
Please read the Description of Coverage for a full explanation This insurance coverage, offered by WorldTrips, is
of your benefits and exclusions using the link at the bottom of not subject to and does not meet the minimum
the following page. standards required by the Affordable Care Act
(PPACA). The policy contains the plan benefits you

In this fulfillment: have selected, including a lifetime maximum. Please

review your choices to ensure you have sufficient
Link to the Description of Coverage • Your Coverage Details •
coverage to meet your medical needs.
Instructional Information • ID Card(s) • Your Receipt

Getting Medical Treatment: Filing a Medical Claim:

• Show your ID card to the medical attendant • Submit original, itemized bills, and any payment receipts, and
• Pay the deductible or copay (if applicable) claim form
• The medical office may submit bills directly • Claims must be ¿led within 60 days of the termination date of
• After the visit, you will need to submit a Claimant's your policy
Statement http://www.worldtrips.com/downloads/worldtrips_claimants_stateme
nt.pdf

Student Zone Contact Us

https://zone.worldtrips.com/clientzone/ • Phone: 1-800-605-2282 (within the U.S.)
• Print a Visa Letter 1-317-262-2132 (outside the U.S.)
• Reprint an ID card
• Extend coverage • Email: service@worldtrips.com
• Update your info

Pre-Existing Conditions Coverage Renewals, Extensions and Cancellation

Coverage for pre-existing conditions is excluded:
• During the first six (6) months of coverage
under StudentSecure Elite and Select, and
• During the first twelve (12) months of
StudentSecure Budget coverage
• StudentSecure Smart includes coverage for the
acute onset of pre-existing conditions ONLY
• Read the Description of Coverage for a full list
of policy exclusions and details
• Renew in advance for a 12-month certificate period.
Deductible and coinsurance must be re-satisfied as of each
renewal date
• Extend and renew policies online in the Student Zone with
payment by credit card
• Free to cancel before effective date
• $25 fee to cancel on or after effective date
• Monthly policies will receive a refund for unused whole
months only
• Policies paid up-front must be cancelled within first 60 days
and have no claim on file, and will receive a prorated refund
on unused days only

WorldTrips Lloyd’s, London

WorldTrips is a member of the Tokio Marine HCC group of companies. WorldTrips has authority to enter into contracts of insurance on behalf of the Lloyd’s underwriting
members of Lloyd’s Syndicate 4141, which is managed by HCC Underwriting Agency Ltd.

KHE2FFFYH6SP-152-680
 StudentSecure®
ID Number: 200043123

Participant Name: Participant Mailing Address:

Deep Chetanbhai Shukla Omkar,1-Bhaktinagar Society,
Near Kanta Stri Vikas Gruh
Rajkot, 360002
India

Citizenship of Participant: India Effective Date: September 5, 2021

Home Country of Participant: India Termination Date: September 3, 2022
Country of Assignment: United States Length of Coverage: 364 days

Actual effective date and period may vary based on the provisions of this coverage.

Coverage: StudentSecure® SMART - Including the US

Certificate Period Maximum: $ 200,000 Participant

Deductible: $ 50 per Incident / In-network or outside U.S

Medical Evacuation: $ 50,000 Lifetime Maximum

Repatriation of Remains: $ 25,000 Lifetime Maximum
Online Fulfillment: Yes
Shipping Charges: $0.00

Purchase Date: 8/28/2021

Paid By: Jaydeep Pandya
Total Paid: $ 371.28

Plan Administrator: WorldTrips

251 N. Illinois St., Ste 600
Indianapolis, IN 46204

This Declaration Page is evidence of your insurance under The Atlas/International Citizen Group Insurance Trust, Hamilton,
Bermuda. For a complete copy of the Master Policy, contact WorldTrips.

A summary of the coverage available under this plan is available at: http://www.worldtrips.com/docs/4531150421.pdf.

Unique Market Ref. No. B6021RAM00221

 POLICYHOLDER/CERTIFICATE HOLDER NOTICE
U.S TREASURY DEPARTMENT'S OFFICE OF FOREIGN ASSETS CONTROL ("OFAC")

It is important to note that no coverage is provided by this Policyholder/Certificate

Holder Notice nor can it be construed to replace any provisions of your plan. For
complete information on provided coverage, consult the plan itself and the Declaration
page. This Policyholder/Certificate Holder Notice is solely for providing information
concerning the possible impact on your insurance coverage due to directives issued by
OFAC, and it is necessary that this notice be read carefully. OFAC administers and
enforces sanctions policy based on national emergency declarations made by the
President and has identified numerous countries, foreign agents, front organizations,
terrorists, terrorist organizations, and narcotics traffickers as "Specially Designated
Nationals and Blocked Persons (“SDN”)". This list can be found on the United States
Treasury's web site - http//www.treas.gov/ofac. In accordance with OFAC regulations, if
it is determined that the insured or any person or entity claiming the benefits of this
insurance has been identified as a SDN or if a prohibited country as identified by OFAC
is involved, then the provisions of the insurance plan will be immediately subject to
OFAC administration. Accordingly, certain limitations on premium payments and/or
claim payments may apply.
 Provider Claim Submission
Provider UnitedHealthcare Member ID: 603200043123
· All claims must be submitted with the 12 digit UnitedHealthcare Member ID
Member Insurance · For member benefit and eligibility verification, call 844-251-0747
Member Name (Surname, Given Name): Payer ID: · Submit claims electronically using PAYER ID USN01
Shukla, Deep Chetanbhai USN01 · Or submit via mail:
UnitedHealthCare Global, PO Box 30526, Salt Lake City, UT 84130-0526
Health Plan (80840): F
WorldTrips Certificate #: 911-87601-04 O Member Claim Submission
200043123 Group Name: L Member WorldTrips Certificate #: 200043123
Effective Date: WorldTrips · Claimant statement and authorization forms may be completed online at
D https://zone.worldtrips.com/clientzone
September 05, 2021 UnitedHealthcare Group Number
· Printable claimant statement and authorization forms are available at
76-570032 https://service.worldtrips.com
UnitedHealthcare Member ID · For additional information call: 800-605-2282 or 317-262-2132
603200043123 · US provider network search: https://www.whyuhc.com/worldtrips
· Non-US provider network search:
Plan Name: https://www.worldtrips.com/find-a-doctor
UnitedHealthcare Options PPO
POSSESSION OF THE CARD DOES NOT GUARANTEE COVERAGE
 Discount Pharmacy & Medical Savings Card
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____________________________________________________________________________________

Payment Receipt

For Certificate: 200043123

Paid By: Jaydeep Pandya
Payment Type: VISA
Number: xxxxxxxxxxxx2551
Amount: $371.28
Date Paid 8/28/2021

Credit Card Payments Only

Expiration Date: 02/2024
Trans. Code: 7037645777
Auth. Code: 007003

WorldTrips
251 North Illinois Street, Suite 600
Indianapolis, IN 46204
____________________________________________________________________________________
 Data Protection Notice for Citizens and Residents of the European Union and for
Visitors Traveling to the European Union.
WorldTrips respects your right to privacy. In our Privacy Policy (available at
https://www.worldtrips.com/about-worldtrips/privacy-policy/) we explain who we are, how we
collect, share and use personal information about you, and how you can exercise your privacy
rights. If you have any questions or concerns about our use of your personal information, then
please contact DPO@tmhcc.com.

We may collect your personal information such as name, email address, postal address,
telephone number, gender and date of birth. We may also collect your sensitive personal
information such as data relating to your physical or mental health or condition. We need the
personal or sensitive personal information to enter into and perform a contract with you. We
retain personal information and sensitive personal information we collect from you where we
have an ongoing legitimate business need to do so.

We may disclose your personal or sensitive personal information to:

 our group companies.

 third party services providers and partners who provide data processing services to
us or who otherwise process personal information for purposes that are described in our
Privacy Policy or notified to you when we collect your personal information;
 any competent law enforcement body, regulatory, government agency, court or
other third party where we believe disclosure is necessary (i) as a matter of applicable
law or regulation, (ii) to exercise, establish or defend our legal rights, or (iii) to protect
your interests or those of any other person;
 a potential buyer (and its agents and advisers) in connection with any proposed
purchase, merger or acquisition of any part of our business, provided that we inform the
buyer it must use your personal information only for the purposes disclosed in our
Privacy Policy; or
 any other person with your consent to the disclosure.

Your personal and sensitive personal information may be transferred to, and processed in,
countries other than the country in which you are resident. These countries may have data
protection laws that are different to the laws of your country. We transfer data within the Tokio
Marine group of companies by virtue of our Intra Group Data Transfer Agreement, which
includes the EU Standard Contractual Clauses.

We use appropriate technical and organisational measures to protect the personal information
that we collect and process about you. The measures we use are designed to provide a level of
security appropriate to the risk of processing your personal information.

You are entitled to know what data is held on you and to make what is referred to as a Data
Subject Access Request (‘DSAR’). You are also entitled to request that your data be
corrected in order that we hold accurate records. In certain circumstances, you have other
data protection rights such as that of requesting deletion, objecting to processing,
restricting processing and in some cases requesting portability. Further information on
your rights is included in our Privacy Policy.

You can opt-out of marketing communications we send you at any time. You can exercise
this right by clicking on the “unsubscribe” or “opt-out” link in the marketing e-mails we send
you. Similarly, if we have collected and processed your personal or sensitive personal
information with your consent, then you can withdraw your consent at any time.
Withdrawing your consent will not affect the lawfulness of any processing we conducted prior to
your withdrawal, nor will it affect processing of your personal information conducted in reliance
on lawful processing grounds other than consent. You have the right to complain to a data
protection authority about our collection and use of your personal information.
 August 28, 2021
CONFIRMATION OF COVERAGE

We are pleased to confirm your short‐term medical coverage under StudentSecure®, underwritten by Lloyd’s Syndicate 4141, 
and administered by WorldTrips, a member of the Tokio Marine HCC group of companies. WorldTrips has authority to enter 
into contracts of insurance on behalf of the Lloyd’s underwriting members of Lloyd’s Syndicate 4141, which is managed by 
HCC Underwriting Agency Ltd. Lloyd’s is authorized as an insurer in Spain by the Spanish insurance regulatory authority 
(Dirección General de Seguros y  Fondos de Pensiones) under reference L0017.  

This coverage is valid worldwide; including the country of assignment listed below, except for the member's home country, 
the United States when the coverage area below indicates 'Excluding the U.S.', and countries restricted by U.S. economic 
sanctions and embargo programs. For U.S. citizens, the home country is always the U.S. For non‐U.S. citizens, the member's 
home country is listed below.

Certificate Number: 200043123

Covered Individual: Deep Chetanbhai Shukla

Effective Date: September 5, 2021

End Date: September 3, 2022

Monthly Payment 
Paid in full VISA
via:

Home Country: India

Country of Assignment: United States

StudentSecure®   Smart
Certificate Period Maximum $200,000 (€170140.0000*)Two Hundred Thousand US Dollars
Maximum Benefit per Injury/Illness (includes COVID‐19) $100,000 (€85070.0000*) One Hundred Thousand US Dollars
Deductible
          In‐network, outside U.S. or student 
          health center $50 (€42.5350*) Fifty US Dollars
          Out‐of‐network $100 (€85.0700*) One Hundred US Dollars
          ER deductible $350 (€297.7450*) Three Hundred Fifty US Dollars
Emergency Medical Evacuation $50,000 (€42535.0000*) Fifty Thousand US Dollars
Emergency Reunion $1,000 (€850.7000*) One Thousand US Dollars
Repatriation of Remains $25,000 (€21267.5000*) Twenty‐Five Thousand US Dollars
Personal Liability $0
Coverage Area Including US

Coinsurance may apply for expenses after the deductible. Other limitations and exclusions do apply.  Please see policy 
documents for further details, or feel free to contact us with any questions or concerns.
COVID 19: Covered same as any other illness to the above mentioned maximum benefit per injury/illness.
Sincerely,

Mark Carney
WorldTrips
Plan Administrator for Lloyd’s, Fitzwilliam House, 10 St. Mary Axe, London, England   EC3A 8BF 

* Plan pays in US Dollars only. Amounts in Euros are provided for convenience and are based on conversion rate as of  August 28, 2021

WorldTrips
251 North Illinois Street, Suite 600, Indianapolis, IN, 46204 USA • Tel: 317‐262‐2132 • Fax: 317‐262‐2140 • Toll Free: 800‐605‐2282 • worldtrips.com