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Note for Parent(s)/Guardian(s):

Your participant’s iNext travel insurance policy reimburses you in the event that
your participant needs medical care abroad or experiences a loss or theft. In most
cases, participants will be expected to pay for related costs up front and should
have access to emergency funds. However, we recognize that situations may arise
where your participant is not able to cover those costs in the moment. CIEE
requests that you fill out the form on the following page which allows our in-
country staff to pay these costs upfront if necessary and then submit the claim to
iNext directly so there are no delays in getting your participant the support they
need.

For more information on iNext travel insurance, please view this reading or visit
the iNext website (CIEE purchases the Comprehensive Ultimate plan for High
School Summer Abroad participants). Once your participant is enrolled, you will
have the ability to purchase additional coverage at your own cost, such as the trip
cancellation or interruption benefits.

1
High School Summer Abroad
Last Modified: January 28, 2021
 iNext Travel Insurance
Assignment of Plan Benefits

Date (dd/mm/yyyy): / /

PAY BENEFITS TO: PARTICIPANT INFORMATION:

CIEE PARTICIPANT NAME:

Phone: 1-866-583-0332; 1-207-553-4292 EMAIL ADDRESS:

LOCATION (City, Country)

TERM (session dates):

AUTHORIZATION

I (print plan member name) understand that I alone am financially responsible to

I hereby understand that this assignment of plan benefits authorization will be kept on file for the duration of the plan period
and may be shared with the claims administrator as needed.

I also understand that the expenses associated with any claim(s) may not be covered by or may indeed exceed all of my available
plan benefits.

I UNDERSTAND that it is illegal to knowingly file a false or fraudulent claim or to knowingly help someone else file one. I have
read and understand the Fraud Notices on page 2 of this document.

Plan Member’s Signature (participant): Date: / /

*********************************************************************************************************
(If Plan Member (participant) is a Minor)

Parent/Guardian Full Name (please print):

Parent/Guardian Signature: Date: / /

General: 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.
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 fines or confinement in prison,
or any combination thereof.
District of Columbia: 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.
Maryland: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who
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.
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.
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.
Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurance company files a statement of claim
or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
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 a crime.
Louisiana: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
Missouri: An insurance company or its agent or representative may not ask an applicant or policyholder to divulge in a written
application or otherwise whether an insurer has canceled or refused to renew or issue to the applicant or policyholder a policy
of insurance. If a question(s) appears in this application, you should not renew it.
Pennsylvania: 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 subjects such person to
criminal and civil penalties.
Puerto Rico: Any person who, knowingly and with the intent to defraud, presents false information in an insurance request form,
or who presents, helps or has presented a fraudulent claim for the payment of a loss or other benefit, or presents more than one claim
for the same damage or loss, will incur a felony, and upon conviction will be penalized for each violation with a fine of no less than
five thousand (5,000) dollars nor more than ten thousand (10,000) dollars, or imprisonment for a fixed term of three (3) years,
or both penalties. If aggregated circumstances prevail, the fixed established imprisonment may be increased to a maximum of five (5)
years; if attenuating circumstances prevail, it may be reduced to a maximum of two (2) years.
Washington: Any person who knowingly presents a false or fraudulent claim for payment of a loss or knowingly makes a false
statement in an application for insurance may be guilty of a criminal offense under state law.”
All Other States: 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 subjects such person to
criminal and/or civil penalties.

EFFECTIVE
DATE
This Notice is effective May 16,
2014.