WorldTrips

251 North Illinois Street, Suite 600, Indianapolis, IN, 46204 USA
Tel: 317-262-2132 Fax: 317-262-2140 Toll Free: 800-605-2282
[email protected]
worldtrips.com
Veysel Bekir Macit WorldTrips
wiener strasse 4/9 http://
Graz, 8020 800-605-2282
Austria [email protected]

The Atlas Series

THANK YOU!
Thank you for purchasing an Atlas Series travel medical
IMPORTANT
insurance plan. Please read the Description of Coverage This insurance coverage, offered by WorldTrips, is
for a full explanation of your benefits and exclusions not subject to and does not meet the minimum
using the link at the bottom of 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
Link to the Description of Coverage • Your Coverage Details • review your choices to ensure you have sufficient
Instructional Information • ID Card(s) • Your Receipt coverage to meet your medical needs.
• Visa Letter

Getting Medical Treatment: Filing a Medical Claim:

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

Client Zone Contact Us

https://zone.worldtrips.com/clientzone/ • Phone: 1-800-605-2282 (within the U.S.)
• Reprint a Visa Letter 1-317-262-2132 (outside the U.S.)
• Reprint an ID card Collect calls accepted
• Extend Coverage
• Update your info • Email: [email protected]

Notable Exclusions Cancellation

• Coverage for pre-existing conditions is excluded • Free to cancel before effective date
from coverage • $25 fee to cancel on or after effective date
• Coverage for acute onset of a pre-existing • Prorated refund on unused days only
condition is excluded when the pre-existing • No cancellations if a claim has been filed
condition is a congenital or chronic condition
• Expenses related to cancer of any form are
excluded
• Read the Description of Coverage for a full list of
policy exclusions

WorldTrips Lloyd’s

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. Lloyd’s is authorized as an insurer in Spain by the
Spanish insurance regulatory authority under reference L0017.

KHE2FFFYH6SP-152-657
 The Atlas Series

Member Name (ID Number, Citizenship): Mailing Address:

Veysel Bekir Macit (130122809, Turkey) wiener strasse 4/9
Graz, 8020
Austria

Home Country: Austria

Effective Date: October 20, 2021
Termination Date: November 28, 2021
Length of Coverage: 40 days

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

Coverage: Atlas International

Overall Maximum Limit: $100,000
Maximum per Injury / Illness: $100,000
Deductible: $0
Optional Coverage None
(if elected):
Online Fulfillment: No
Shipping Charges: $0.00

Purchase Date: October 19, 2021

Paid By: VISA
Total Paid: $64.80

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/1001150421.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: 603130122809
· 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
Macit, Veysel Bekir 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
130122809 Group Name: L Member WorldTrips Certificate #: 130122809
Effective Date: WorldTrips · Claimant statement and authorization forms may be completed online at
D https://zone.worldtrips.com/clientzone
October 20, 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
603130122809 · 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
____________________________________________________________________________________

Payment Receipt

For Certificate: 130122809

Paid By: veysel bekir macit
Payment Type: VISA
Number: xxxxxxxxxxxx2986
Amount: $64.80
Date Paid 10/19/2021

Credit Card Payments Only

Expiration Date: 10/2026
Trans. Code: 7203428349
Auth. Code: P97CHV

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 [email protected].

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.
 October 19, 2021 CONFIRMATION OF COVERAGE

We are pleased to confirm short term medical coverage under the Atlas Series, insured 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 plan will make direct payment to providers when the plan administrator is contacted and 
submitted charges are approved.

This coverage is valid worldwide, including the Destination Country(ies) listed below, except for the member’s Home Country and 
countries restricted by U.S. economic sanctions and embargo programs. Atlas Travel satisfies Schengen Visa health insurance 
requirements.  

Effective Date:   October 20, 2021

Home Country: Austria
Destination Country(ies): Colombia

Name Certificate  Termination Date Passport Citizenship

Veysel Bekir Macit 130122809 11/28/2021 Turkey

Atlas Travel
Overall Policy Maximum $100,000 (€85740.0000*) One Hundred Thousand US Dollars
Maximum per Injury/Illness   Overall Maximum Limit
Deductible $0 (€0.0000*) Zero US Dollars
Medical Expenses (including hospitalization)  (includes COVID‐19) Overall Maximum Limit
Emergency Medical Evacuation & Repatriation $1,000,000 (€857400.0000*) One Million US Dollars
Emergency Reunion $100,000 (€85740.0000*) One Hundred Thousand US Dollars
Repatriation of Remains Overall Maximum Limit
Trip Interruption $10,000 (€8574.0000*) Ten Thousand US Dollars
Personal Liability $25,000 (€21435.0000*) Twenty Five Thousand US Dollars
Emergency Dental due to Accident Overall Maximum Limit
Emergency Dental ‐ Acute Onset of Pain $300 (€257.2200*) Three Hundred US Dollars
Paid in full by VISA

This coverage is extendable up to the maximum certificate duration.  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 medical maximum.
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  October 19, 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