Enrollment Options

Enrollment Options
Exclusions & Limitations
Meet Your Travel Needs
Before you leave home, consider the unexpected. It’s
important to protect you and your trip investment in today’s
travel environment. Meet your essential travel needs with
our value-driven plan and find the peace of mind your trip
deserves with these important plan highlights:
If you wish to obtain a fraud statement specific to your state of residence, please
call 1-800-819-9004.
The following exclusion applies to the Medical Expense, Trip Cancellation, Trip
Interruption, and Trip Delay coverages:
We will not pay for loss or expense caused by or incurred resulting from a Pre-Existing
Condition, as defined in the plan, including death that results therefrom. This exclusion
does not apply to benefits under Medical Evacuation and Repatriation Benefits.
The following exclusion applies to the Accidental Death & Dismemberment coverage: We
will not pay for loss caused by or resulting from Sickness of any kind.
The following exclusions apply to all coverages:
We will not pay for any loss under the plan, caused by, or resulting from: suicide,
attempted suicide, or intentionally self-inflicted injury, while sane or insane (while
sane in CO and MO); mental, nervous, or psychological disorders (does not apply to
Medical Expense Benefits); being under the influence of drugs or intoxicants, unless
prescribed by a physician; normal pregnancy or resulting childbirth or elective abortion;
participation as a professional in athletics; riding or driving in any motor competition;
declared or undeclared war, or any act of war; civil disorder (does not apply to Trip
Delay); service in the armed forces of any country; operating or learning to operate
any aircraft, as pilot or crew; mountain climbing, bungee cord jumping, skydiving,
parachuting, hang gliding, parasailing or travel on any air supported device, other than
on a regularly scheduled airline or air charter company; any criminal acts, committed
by you; a loss or damage caused by detention, confiscation or destruction by customs;
elective treatment and procedures; medical treatment during or arising from a covered
trip undertaken for the purpose or intent of securing medical treatment; a loss that
results from an illness, disease, or other condition, event or circumstance which occurs
at a time when the plan is not in effect for you.
Please refer to your Description of Coverage for Baggage/Baggage Delay and Rental
Car Damage exclusions.
DEFINITIONS: Pre-Existing Condition means an illness, disease, or other condition
during the 60 day period immediately prior to your effective date for which you
or your Traveling Companion, Domestic Partner, Business Partner or Family
Member scheduled or booked to travel with you: 1) received or received a
recommendation for a diagnostic test, examination, or medical treatment; or
2) took or received a prescription for drugs or medicine. Item (2) of this definition
does not apply to a condition which is treated or controlled solely through the taking
of prescription drugs or medicine and remains treated or controlled without any
adjustment or change in the required prescription throughout the 60 day period before
coverage is effective under this Policy.
New York Residents: The licensed producer represents the insurer for purposes of
the sale. Compensation paid to the producer may depend on the policy selected, the
producers expenses or volume of business. The purchaser may request and obtain
information about the producer’s compensation except as otherwise provided by law.
California Residents: You should review your existing policies for coverage. If you
have questions about your current coverage, call your insurer. California Insurance
Department: Toll free consumer hotline is 1-800-927-7357. We are doing business
in California as Travelex Insurance Services, Inc. 1121 North 102nd Court, Suite
202, Omaha, NE 68114. Agency License #0D10209. Toll free 1-800-228-9792.
Email: [email protected]
Travel Insurance is underwritten by Stonebridge Casualty Insurance Company a
Transamerica company, Columbus, Ohio; NAIC #10952 (all states except as otherwise
noted) under Policy/Certificate Form series TAHC5000. In CA, HI, NE, NH, PA, TN and TX
Policy/Certificate Form series TAHC5100 and TAHC5200. In IL, IN, KS, LA, OR, OH, VT,
WA and WY Policy Form Numbers TAHC5100IPS and TAHC5200IPS. Certain coverages
are under series TAHC6000 and TAHC7000.
This brochure is a brief summary of the program, please review the Description of
Coverage for an outline of benefits and amounts of coverage available to you. Your
Individual Policy or Group Certificate will govern the final interpretation of any provision
or claim. To view your state-filed form, please visit www.travelexinsurance.com/
SBPlans.aspx or call 1-800-819-9004 to obtain your Individual Policy in the following
states: IL, IN, KS, LA, OR, OH, VT, WA and WY or your Group Certificate for all other states.
© 2012 Travelex Insurance Services, Inc. 25759076
5
6
Travel Agent
Contact your local travel agent.
Internet
Visit us at www.travelexinsurance.com to get a
quote, learn more or to purchase.
Phone
Speak with an experienced customer service
representative available at 1-800-235-7178,
M-F 8:00 am to 7:00 pm CST, to answer questions,
receive a quote or to enroll.
Fax or Mail
Fax both sides of enrollment form to 1-800-867-9531
or mail to: Travelex Insurance Services, PO Box
641070, Omaha, NE 68164-7070.
Payment Details
Check or Money Order (payable to Travelex Insurance Services)
Visa®
MasterCard®
Discover®
American Express®
Credit Card Number ___ ___ ___ ___ /___ ___ ___ ___ /___ ___ ___ ___ /___ ___ ___ ___
Credit Card Expiration Date
MM / YYYY
Print Full Name
(As appears on credit card)
Signature
(Mandatory for all payment types)
Date
MM
/
DD
/
YYYY
Plan fees are non-refundable after 10 day free look period.
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.
Travel Basic
Essential Travel Protection
Primary Coverage
Easy claims handling, less time and hassle to receive
reimbursement for eligible losses from us first, with no
deductibles, before any other collectible insurance.
Post Departure Protection
Select the $0 trip cost level if you don’t need cancellation
coverage. Receive all other base plan benefits, plus $500 in
trip interruption coverage.
Ten Day Free Look
If you are not completely satisfied within 10 days of
purchasing this plan, Travelex will refund your premium
cost, if you have not departed on your trip or filed a claim.
Like us on Facebook!
facebook.com/TravelexInsurance
Exclusive Brochure
Please utilize the location number
and agent code below when
getting a quote or enrolling.
LOCATION NUMBER
AGENT CODE
09-5034
COMPANY NAME
PREFERRED TRAVEL OF
NAPLES
0812
7
STB-SIG 0811
STB-SIG 0811
Benefit Highlights
Benefits & Rates
Trip Cancellation & Interruption
Base Plan Benefits
Protectt trav
Protec
travel investmen
ments and recover non-refundable,
pre
r paid
d trip
trip co
costs
st if a tri
trip
p is cancelled or interrupted due to
a covered re
reaso
ason.
n. Ref
Refer to the Description of Coverage for
complete details.
Trip Cancella
at o
ation
100% of trip cost ($10,000 limit)
Trip Interruptiion
100% of trip cost ($10,000
(
limit)
•
•
•
•
•
•
•
•
Baggag
Bag
gage/B
e ag
aggage Delay
Sickness, Injury or Death
Financial Insolvency
Residence Uninhabitable
Trafficc Ac
Accid
cident
cid
e en Route
en
ent
Invvolunt
In
olu
l ntaary Empploy
loymen
m t Term
me
Termination/Transfer
M
Mili
ilitar
ili
t yD
tar
Duty
uty foor Natu
Natura
rraal
al Di
D sas
sa ter
Deaath/Hos
De
th/Hos
Hospit
pitaalizat
pit
lizat
za ion off Deesti
stinat
nation
nat
ion Ho
Host
st
Common
on Car
Ca rie
rierr Cance
anc
ncellati
ell tion
ons/Delayss
•
•
•
•
•
•
•
Weather
Strike
Quarantine
Hijacki
cking
ng
Jury Du
Duty
tyy
Subpoena
Documented
Passport/Visa Theft
Reasons to Buy
Coverage Per Person†
Trip Dela
ay/M
y/Missed
e Cruise Connection
$500
$500 / $100
Emergency
Eme
cy Accident Medical Exp
pens
e e
$15,000
Em
merg
merg
gency Sickn
ness Medi
Medical Expense
Exp
xp
p
$15,000
Eme
ergency
rge
g ncy Me
Medic
d all Evacuation/Re
ep
pa
atri
t ati
ation
on
$10
1 0,0
0,000
000
Travvel
Tra
vel As
Asssistan
sista
an
nce
e & Concierge*
Inc
nclud
lud
uded
ed
e
d
Traveling creates memories of a lifetime and
nd can also
so me
ean
encountering the unexpected. Travel Basic meets
me ts
s the
challenges of today’s travel for you to enjoy a wo
orry-fre
re
ee trip
p!
Provid
Prov
des rei
re mbu
mburse
semen
mentt for
f
additi
add
itionall c
cost
o s such as
ost
accomm
acc
ommoda
od
datio
tions
ns,, tr
t ans
anspo
portation,, an
and mea
eals
ls if a trip is
de aye
del
ed 5 hours
urs or
o mo
more
re for a cov
vere
red
d reas
e on
on.
†
Trip Details
Location Number / Agent Code
Departure Date
• The cruise line for your trip decl
clare
cl
a s bank
are
bankrup
uptcy
tcy
Country of Destination
• You hav
ave a medical emergencyy du
during a shore excursion
Tour Operator
• A flfligh
ightt delay
d
causes you to miss a connection
Cruise Line
• Upon
on ar
arriv
arriv
rival
a at you
al
yourr dest
destina
inatio
tionn your
your lu
lugga
gg ge is not foundd
$200,000
$35,000
00
Optional Upgrade
MM
/
DD
/
YYYY
Airline
Primary Traveler Full Name
MM
/
/
YYYY
Trip Cost $
/
YYYY
Trip Cost $
/
YYYY
Trip Cost $
YYYY
Trip Cost $
DD
Second Traveler Full Name
Birth Date
MM
Birth Date
Base Plan Rates Per Person
Use full cost per person,
include all non-refundable,
prepaid travel costs.
Ages
0-34
Ages
35-50
Ages
51-59
Ages
60-69
Ages
70-79
Ages
80+
$0
0 excludes
excludes trip cancel
exclu
anc latio
lation**
n
n**
$20
$25
$29
$29
$32
2
$36
$67
67
7
$500
$23
$31
$39
$45
$56
$88
Address
- $1,0
$1,000
00
$31
$40
$49
$55
$76
$132
City
$1
Baggage & Baggage Delay
$501
$50
-
MM
/
DD
Birth Date
MM
$1,001 - $1,500
$40
$54
$58
$74
$96
$184
$1
$1,5
1 01
01 - $2,00
2,000
0
$
$5
$53
$67
67
7
$7
$7
$76
$100
$133
$235
235
Beneficiary Name
Emergency Medical Expenses
$2,001 - $2,500
$68
$85
$95
$122
$162
$286
Pro
rovid
vid
des cov
covera
era
erage
rage for em
emerg
erg
genc
ency
n y med
medi
ed cal tr
t eat
ea men
m t if
if
a sick
sick
i k nes
ness o
ne
orr i nju
njury
u ry occ
o ccurs
occu
oc
urs
ur
rs wh
w h ile
whi
i l tr
trave
avelin
ave
li g.
lin
g
$ 01
$2,5
01 - $
$3,00
3,00
00
00
$81
$
$10
$100
$112
$1
12
$144
$144
$192
$338
$3,001 - $3,500
$101
$116
$134
$167
$264
$389
Emergency Medical Evacuation
$3,5
501
01 - $4
$4
4,00
000
0
$ 29
$129
$145
5
$ 65
$1
$165
$188
188
8
$3
$30
$300
$
30
$44
$440
440
0
Pr vid
Pro
vides cov
covera
er ge
era
g fo
for
or em
eme
merg
ergenc
er
ncyy evacuat
nc
vac
vac
cuat
uattion
ua
on
n, iff n
nece
ece
c ssa
ssary,
ry
to
o the
he ne
eare
arest
s qua
st
qualif
lilified
ied me
m dic
dic
cal
al fac
a ilililty,
t al
ty
a so inc
nclud
nc
u es
ud
e
rep
ep
patr
atriat
iat
a ion
on..
$4,001 - $4,500
$143
$164
$193
$236
$334
$491
$4
$4,5
4 501
01 - $
$5,00
5,, 0
5,00
5,0
$159
15
159
59
59
$181
$181
$1
$214
214
2
21
1
14
$
$26
$264
$37
$370
$37
$54
$541
$54
541
4
Fo
For raates
te on trip cost
costss above
above
ov $$5,0
, 0000 pleas
easse ccall 11-8
1-80
-88000-23
-80
-2 5-71178
78.
Maximu
x m trip lengt
ngthh allowe
al oweed 30
3 da
days.
An $88 proc
r essi
ess ngg feee will
willl appl
apply per
per pplan; plan
lan
a s sold perr hhouse
ousehold
ouse
hhold
ho
o .
Ra are subj
Rates
u ec
ect to chang
chang
ha ge.
/
DD
/
Transportation Pak
One up
One
upgra
gra
g
ade
e wi
wit
itth two
wo gre
g at
at ben
benefi
efiits!! Th
The
e pak
ak inc
clud
ludes
es
flilight
g ac
cci
ci ent
cid
ent c
co
ov
verrage
e fo
f r eac
ach
a
c trave
trave
tr
ve
eler
err an
and
nd rent
ntal car
damage
dam
ag prrote
tecti
te
ction.
i n
Ava
A
aila
able
e fo
or an a
addi
d tio
dd
ddi
tional
na
na
al $5
59 per pla
an.
n.
For questions, quotes or to enroll,
visit www.travelexinsurance.com
or call 1-800-235-7178
Primary Traveler Email
(Provide to receive Confirmation of Coverage via email)
Premium Calculation
Total Base Plan Rate
$
(calculate below for all travelers)
+ $
+ $
Second Traveler
Optional Transportation Pakk
+ $
Third Traveler
3
Fourth Traveler
=
$
Base Plan Total
$
($59)
Processing Fee
$
Total Amount Due
$
(and authorized as payment)
* Prov
Provided
ided by Trav
a elex
av
elex’s
’s desig
s nate
natedd assist
assisttance
ance pro
provide
vider.
2
Zip
(Estate designated if left blank)
Primary Traveler
•
•
•
•
DD
State
Safegu
Saf
eguard
ard
ds pers
ersona
ona
n l arti
arti
t cle
cless and exp
e ens
en es iff bags
bag
ags a
are
re los
ost,
os
t,
stolen
sto
len,, d
len
dama
am ged
ama
ged,, or
or dela
dela
elayed
yed fo
for 12 hourrs or
or more
e.
** Receive
Rece
eceive
ve all
al other
othe
her base
basee pplan
la benefits
lan
f s inc
includi
luding
ng $500
$500 in trip
rip inte
interrupption
in
tio
ion
on co
covveerag
r e.
/
Fourth Traveler Full Name
Daytime Phone
1
Return Date
YYYY
Limitations and exclusions apply. Refer to your Description of Coverage for full details.
Trip Cost
Includ
Inc
ludes
lud
e s rei
es
reimbu
mburse
mbu
rsemen
rse
mentt ffor
men
or unu
n sed
d, n
non
on-ref
refund
und able
bl
exp
pens
enses
ses
es and
d ad
addit
ddit
ditional
al cos
ostts
ts suc
such
u h a
as
s acco
ac
cco
co
ommo
mmodat
mmo
dation
dat
ions
ion
s,
s,
tra
ra
ansport
nsp
sport
ortati
ation a
and
d me
meals
lss if
i your
your
yo
ur con
connec
nnec
nectio
tion
tio
n is miss
miss
issed
d by
by
3 hour
hour
ou s o
orr more
more
o ffo
or a co
c ver
v ed
ed rea
ea
ason
son.
Inc
nclud
lud
lu
udess a w
u
wide
ide
de ra
range
ng
nge
g of
o se
ervi
r ces
c b
be
efor
ore and
and
nd dur
during
during
ng
n
g ttrrips
ips
thr
hrough
oug
ugh a 24
24/7
/7 tol
/7
o l free
ee
e nu
number.
mbe
m
be
er Inc
Inc
clud
u ess a
asssist
i anc
is
a e with
th
med
e ica
ca
al emer
me
ergen
encie
cie
i s,
s los
lostt docu
umen
me ts
t or
o bag
aggage, eve
vent
n
tic
ic
cket
keting
ing,, busi
usines
nes
e s serv
e ice
c s, and
ce
a mu
m ch
c mor
more.
e
/
DD
Third Traveler Full Name
Missed Cruise Connection
Travel Assistance & Concierge*
/
MM
Traveler Details
Birth Date
• Flight Accident AD&D (per
(pe person)
• Rental Carr Damag
Damage Protection
ion (per
per pla
plan)
n)
STB-SIG 0811
TAHC5001GES
(on pg 7 of brochure)
Transportation Pak
Trip Delay
Please print clearly for accurate processing.
• You or a family member become illl and
a yo
y u can
can no lon
longer
g tr
t avel
• You los
l e your
ur pa
p ssp
s ort and need assistance to ret
return
urn ho
hom
me
me
Optional Upgrades
Enrollment Form
4
8.00
Enrollment Form
Enrollment Options
Please print clearly for accurate processing.
STB-SIG 0811
TAHC5001GES
Travel Agent
Trip Details
Location Number / Agent Code
Contact your local travel agent.
09-5034
(on pg 7 of brochure)
Departure Date
/
MM
/
DD
Return Date
YYYY
MM
/
DD
/
Internet
YYYY
Visit us at www.travelexinsurance.com to get a
quote, learn more or to purchase.
Country of Destination
Tour Operator
Airline
Cruise Line
Phone
Traveler Details
YYYY
Trip Cost $
Speak with an experienced customer service
representative available at 1-800-235-7178,
M-F 8:00 am to 7:00 pm CST, to answer questions,
receive a quote or to enroll.
YYYY
Trip Cost $
Fax or Mail
YYYY
Trip Cost $
Fax both sides of enrollment form to 1-800-867-9531
or mail to: Travelex Insurance Services, PO Box
641070, Omaha, NE 68164-7070.
YYYY
Trip Cost $
Primary Traveler Full Name
Birth Date
MM
/
/
DD
Second Traveler Full Name
Birth Date
MM
/
DD
/
Third Traveler Full Name
Birth Date
MM
/
DD
/
Fourth Traveler Full Name
Birth Date
MM
/
DD
/
Payment Details
Address
City
State
Check or Money Order (payable to Travelex Insurance Services)
Zip
Daytime Phone
Visa®
MasterCard®
Discover®
American Express®
Beneficiary Name
Credit Card Number ___ ___ ___ ___ /___ ___ ___ ___ /___ ___ ___ ___ /___ ___ ___ ___
(Estate designated if left blank)
Credit Card Expiration Date
Primary Traveler Email
(Provide to receive Confirmation of Coverage via email)
Print Full Name
(As appears on credit card)
Premium Calculation
Total Base Plan Rate
$
(calculate below for all travelers)
+ $
Primary Traveler
+ $
Second Traveler
Optional Transportation Pakk
MM / YYYY
Signature
+ $
Third Traveler
Fourth Traveler
=
(Mandatory for all payment types)
$
Base Plan Total
Processing Fee
$
Total Amount Due
$
(and authorized as payment)
4
MM
/
DD
/
YYYY
Plan fees are non-refundable after 10 day free look period.
$
($59)
Date
8.00
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.
If you wish to obtain a fraud statement specific to your state of residence, please
call 1-800-819-9004.
5