Document 15082

Enrollment Options
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 1-800-228-9792,
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.
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
/
Meet Your Travel Needs
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.
In today’s travel environment it’s important to protect you and
your trip investment. Meet your luxury travel needs with our
maximum coverage plan and find the peace of mind your trip
deserves with these valuable plan highlights:
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; 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.
Receive reimbursement for your eligible losses from
Travelex first, with no deductibles, and before any other
collectible insurance.
Please refer to your Description of Coverage for Baggage/Baggage Delay and
Rental Car Damage exclusions.
Payment Details
®
Exclusions & Limitations
YYYY
Plan fees are non-refundable after 10 day free look period.
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.
Travel Insurance is underwritten by Stonebridge Casualty Insurance Company
an AEGON 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.
If you wish to obtain a fraud statement specific to your state of residence, please
call 1-800-819-9004.
This brochure is a brief description of benefits. Your individual policy
or group policy will govern the final interpretation of any provision or
claim. If you are a resident of one of the following states: IL, IN, KS, LA, OR,
OH, VT, WA, and WY, your coverage is written on an Individual Policy. Please
call 1-800-228-9792 or visit www.travelexinsurance.com/SBPlans.aspx to
obtain your Individual Policy or your Certificate of Insurance for all other states.
© 2011 Travelex Insurance Services, Inc. 24205139
5
6
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.
Primary Coverage
Travel Max
Deluxe Travel Protection
M ad e E a s y
Cancel for Any Reason Upgrade
Purchase this pak for protection against the unexpected.
Cancel your trip for absolutely any reason, plus cancel for trip
delay reasons!
30 Day Pre-Existing Waiver
Purchase the plan within 30 days of initial trip deposit and
pre-existing medical conditions are eligible for coverage.
Post Departure Protection
Select the $0 trip cost level if you don’t need cancellation
coverage. Receive all other base plan benefits, plus $1,000 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.
Please utilize the location number
and agent code below when
getting a quote or enrolling.
LOCATION NUMBER
AGENT CODE
46-0032
COMPANY NAME
International Services
7
STM 0811
STM 0811
Benefit Highlights
Benefits & Rates
Trip Cancellation & Interruption
Base Plan Benefits
Protec
c ts travel inves
vestm
tments if a trip is cancelled or
intterr
errupt
upted
ed. Recoverr non
no -refundable, prepaid trip costs
f or th
the
e ffoll
ollowi
owing
ng cov
overe
ered reasons:
• Sickness, Inj
Injury
ury or De
Death
at
• Weather
• Trip Delay of 50% or more
• Strike
• Financial Insolvency
• Quarantine
• Residence/Destination Uninhabitable
• Hijacking
• Traffic Accident en Route
• Jury Duty
• Involunta
nta
tary
ry Emp
Em loy
l ment Termination/Transfer • Subpoena
• Mili
il tar
taryy Duty
u fo
forr Natu
a ral Disaster
• Terr
errori
orist
ori
st Ac
Act
• D
Dea
eath/
th/Ho
Hos
osppit
pitalizat
pitali
zation
ation
on off De
D stitinat
nation
ion Ho
Host
st
• Man
Man
Mandatory
Evac
acu
cuuati
a on
• Comm
m on
on Car
Carri
rierr Canc
a elllat
aatitons
ons/De
/Delay
layss
• Busi
u ness Reasons**
• Docu
ocumen
menttedd Pa
Pass
ssp
sport
rt/Vi
t /Vi
/V sa The
Thefft
ft
Trip Delay
Provid
Pro
vides
vid
e rei
reimbursemen
ment for ad
a dittion
onal
on
all cos
costs
t such as
ts
accomm
acc
omm
mm
moda
o tio
tions
ns, tr
trans
anspo
portation
on,, meal
eals
ls,
s, int
intern
ern
net usa
us ge
fee
es,
s airrlin
line
ec
club
lub ad
admis
missio
sion
n and ke
enn
nel co
cover
verage
age if a trip is
delayed 5 hours
delaye
urs or mo
more for a cov
vere
red
d rreas
e on.
Missed Cruise Connection
In clu
cludes
d es re
reii mbursseme
e nt for
or un
n use
used,
d non -refundab
re
dable
le
ex ens
exp
enses
es and addition
onal
al cos
c ts suc
such
h as
as acco
accommo
m dation
mm
dattions,
ons,
transp
transp
tra
sp
port
o ati
atiion and
d me
meals
als if yo
y ur
u con
c nection
n is
is miss
missed
ed by
3h
hour
ourss o
our
orr m
more
ore
re
e fo
forr a co
c ver
ered
ed rea
ed
r son
so .
Baggage & Baggage Delay
Safegu
Saf
egu
guard
ard
ds pers
pers
r onal
ona
al art
arti
rticle
cle
es and
and
d exp
expens
enses
ess iff bag
bagss are
are los
lost,
t,
s len
sto
len,, dama
dama
m ged
d, or dela
dela
elayed
yed fo
or 12 hour
hour
ourss or
or m
more
or . Incl
ore
Incl
nclude
ude
dess
cov
covera
o era
erage
ge for
f
perso
pe
rso
onal
na bu
busin
sin
ness
es pr
prope
operty
ope
rty an
and
d a re
enta
ntall
allowa
al
all
owance
owa
nce
ce fo
forr lost
ost,, stol
o en or
o dam
damage
aged
ag
age
d spor
po tin
ing
g equi
equi
u pme
pm nt.
n
nt
Emergency Medical Expenses
Provid
Pro
vides
vid
es cov
covera
er ge
era
g for
fo
or em
emerg
ergenc
erg
ency
enc
y medi
medi
edical
dicall tr
treat
ea men
eat
mentt if
if
a sick
cknes
k nes
e s or inju
inju
njury
ry occ
occurs
urs wh
w ile tr
trave
ave
velin
l g. Inc
lin
Inclu
ludes
lud
es
pr tec
pro
tectio
tion
tio
n for
o travel
tra
ra vel
ve ing
ng
g pe
e ts.
t
Emergency Medical Evacuation
Provid
Pro
Provid
vides
ides cov
overa
erage
era
rage
g fo
forr emerg
for
erg
genc
n y evac
ac
cuat
ation
on
n, if nece
ec
c ssa
s ry,
y, to
t
th ne
the
neare
ar s
stt qua
q lifi
liffied
ied
d me
medic
dical
dic
di
all fac
fa
ac
cilili
ility
liity
t also
ty,
all inc
nclud
lud
ud
des rep
repatr
t iat
a ion
ion..
Accidental Death & Dismemberment
Pro
Pro
ovid
v es
e cov
overa
erage
era
ge for
ge
fo lo
loss
os
ss
s off lif
iffe,
e limbs
b or sightt fro
f m a cover
e ed
acc
ac
cide
de
enta
nt l inju
n ry whi
while
le tra
t vel
ve
e ing
n orr on
o a com
om
ommon
m o carrier.
e
Travel Assistance & Concierge**
Includ
Includ
ud
des
e a wide
d ra
r nge
ng
g of
o se
erviices
c
be
efor
o e and
nd dur
du ing
during
n tr
trips
s
thr
h oug
ug
gh a 24
24/7
/7 tol
olll free
re
e nu
umbe
m er.
r. Inc
nc
clud
ludes
e Nur
u se
e Ass
Assist
iss an
a d
hel
e p with
with
ith
h me
edic
d all eme
merge
me
rge
genci
ge
nci
ncies,
ciies,
e llo
es
ost doc
cume
u entss or bagga
age
ge,
e
event
eve
nt tic
ticket
k ing
ke
ket
ng,
ng
g, b
busi
usines
usi
n s serv
nes
ervice
ic
ice
c s, and
d mu
much
h mor
m e.
* Requir
Requires
ess plan pur
purc
rchase
ase wit
within
hin 30 days
days
ay of initi
initial
al trip
trip depo
dep sit.
1
Maximum Luxuries
Enrollment Form
Please print clearly for accurate processing.
Coverage Per Person
Trip Cancelllat
a on
ati
n
100% of trip cost ($50,000 limit)
Trip Interruptiion
150% of trip cost ($75,000 limit)
Trip Delay/M
y/Missed
ed Cruise Connection
Location Number / Agent Code
(on pg 7 of brochure)
$1,000
Bag
aggag
gage/B
e/Bagg
ag age Delay
Departure Date
$2,500 / $600
Emerge
Eme
rgency
ncy Ac
Accident
ent & Sickness Medical Expense
e
$25,00
$25
,000
0
Common Ca
Commo
arr
rrri
rier AD
AD
AD&D
$50
50,00
,00
0 0
Travel
Tra
vel
el Assistance & Concierge***
In luded
Inc
d
Maximum Luxuries
Transportation Pak
• Flight Accident AD&D
D&D (per
per per
person)
son)
• Rental Ca
Carr Dama
Damage Protec
ction
n (p
(per pla
plan)
Cancel for Any Rea
Reason
son Pak
NO COST!
$200,0
,000
00
$50,00
$50
,000
0
No
Cost!
(use full cost per person)
Ages
35-59
Ages
60-69
Ages
70-79
Ages
80+
$36
$45
$63
$63
$
$83
$
$215
$38
$67
$
7
$96
$12
$120
$158
$185
85
$48
$8
$80
$115
$15
$157
57
$199
$
$236
$68
$11
$117
$163
$206
$253
$2 4
$294
$89
$155
155
5
$219
$285
285
$362
$
$4
$427
$333
$510
0
$547
$724
724
$905
$1
$1,0
1 083
1,0
3
$3,001 - $3,500
$221
$289
$340
$502
$1,265
$3 501
$3,5
$4,001
$4,501
$4,5
0
01
$5,001
$5,5
5,501
01
$6,001
$6,5
$6,501
$6,
,501
01
$7,001
$ 01
$8,0
0
$9,001
$245
$273
$2
$29
$299
29
$352
$37
$378
$412
$44
$441
$515
$587
$669
$327
$367
$418
8
$486
$526
$52
2
26
$585
$628
$6
$
6
$702
$
$812
$911
$388
$429
$470
470
0
$567
$614
614
$678
$713
713
3
$813
$9
$921
$92
921
9
$1,035
$585
$
$680
$76
$
$7
$763
76
76
$820
$868
86
$971
$1,0
,029
029
29
$1,162
$1,3
$
$1,307
1,3
1,30
1
07
7
$1,454
$1,4
1,446
46
6
$1,625
$1,7
1 798
1,798
$1,908
$1,9
$1
$1,9
1 955
55
5
$2,200
$2,3
2 65
65
$2,682
$3 045
$
$3,0
4
$3,444
$1
$501
$50
1
$1,001
$1 01
$1,5
0
$2,001
$2,501
$2,5
01
-
$
$4,00
4,000
0
$4,500
$5,00
,000
0
$5,500
$6,
$6,00
6,00
6
00
00
$6,500
$
$7,00
7,00
7,0
,000
$8,000
$9
9,00
000
0
$10,000
/
DD
/
YYYY
Airline
O e pa
One
On
p k with tw
two
o grea
e t bene
nefit
fits, each auto
toma
m tiica
mat
alllly
inc
ncluded
ed
d in you
yourr b
base
as pllan
ase
a rat
rate! The
Th
he pa
he
ak incl
nc ude
udes
s fflig
light
ht
accide
ent co
cov
overa
erage for
for ea
ach
h trraveler
e and rental car
er
dam
amage
age prote
protection.
on.
n.
Primary Traveler Full Name
Birth Date
MM
/
/
YYYY
Trip Cost $
/
YYYY
Trip Cost $
/
YYYY
Trip Cost $
YYYY
Trip Cost $
DD
Second Traveler Full Name
Birth Date
MM
/
DD
Third Traveler Full Name
Birth Date
MM
/
DD
Fourth Traveler Full Name
Ages
0-34
$500
$1,0
$
1,000
$1,500
$2,00
2,000
0
$2,500
$3,000
$3,00
0
$ exclu
$0
xclu
cludes
ddes trrip cancel
anc latio
ti n***
*
MM
Traveler Details
Transportation Pak
Base Plan Rates Per Person
Trip Cost
Return Date
YYYY
Cruise Line
UPGRADE
75% of trip
ip cos
costt
10 % of
100
of trip
rip co
cost
st
• Cancel for An
ny R
Reason
• Cancel
Can
forr Tri
Trip
p Delay
De ay Reas
easons
o
/
DD
Tour Operator
$1 million
24 Ho
Ho
Hou
ourr AD&D
ou
D&
&
/
MM
Country of Destination
$100,000
Eme
Eme
merg
rge
rg
gency Medical Eva
g
va
acua
cuatio
tion/R
tio
n/ ep
n/R
e triation
epa
STM 0811
Trip Details
** Prov
Pro ided by Travelex’s desig
sig
iggnateed assist
assis
sist
isttan
is
ance
anc
c pro
r videer.r
***
* Rece
ceeive
i allll othe
other baase plan
lan ben
la
bene
be
bene
neffits
it in
includi
ludingg $1,0000 in
ludi
in trip
tririp in
i terr
ter
errupti
upt onn coverage.
overaage.
over
agg
age
• Fo
F r raates
ess on trip
ip cost
costss ab
a ov
ove $10,
10,,000 pleaasee call
alll 1-8
1-88 0-22
1-80
2 8-97
9792.
992.
2
• Ma
Maxim
ximu
xim
mum
m trip
tripp lengt
lengt
ngt
g h allowe
owe
weed 1180 days.
days. Forr trip
tripss 311-180
tri
180
18
80 day
a s inn len
ay
length
g add $88 pper
gth
eerr day.
• An
A $8
$ pro
proc
ocessi
oces
oc
e ngg ffee
ee will
will
il appl
a y pe
app
per pl
p an.
n.
• Ra
Rates
ates
es are
re subj
b ect
e to change.
hang
angge.
e.
2
Birth Date
MM
/
DD
/
Address
Upgrad
City
e
Cancel for Any Reason Pak
Protec
Pro
tectio
tec
tion
tio
n agai
gainst
nstt th
the
e unex
unex
nexpec
pe ted
pec
t , what
whateve
everr iitt may
may b
be!!
be
Purcha
Pur
chase
se
e thi
t s upgr
upgrade
ade an
and
d ever
everyon
yone
e on
on the
the pla
plan
n rece
receive
ives
s
these
the
se two be
benef
nefits
its:
• Cancel a tri
rip
ri
p 2 or
o mo
more
re
e day
da
d
ays befo
fore
re the
he sc
ched
h ule
he
u d depa
artu
r ure
r
d e and re
dat
r ove
rec
ver up to
to 75
5%
% off tri
rip
ri
pc
cost
o .
ost
• Plu
Plus
s Canc
an el fforr Tr
Trip
p Del
De ay
ay Rea
Re sons
son
ns - Th
This
iss add
added
ed
e
d ben
benefi
fit
a ows
al
all
o s ca
cance
ncella
la
atio
on due
d
to 30
30%
0% or
o mo
mo of
more
o a trip
t p being
g
missed
mis
sed
ed from
o a cove
covered
e de
elay
ayy an
nd recove
eco
cover
ve up to 10
100%
0 of
0%
of
triip cost
s.
Mus
u t be sele
electe
cte
ed at th
he
e tim
me off init
initial
i l pllan
n pur
purcha
c se, wi
cha
withi
thi
thin
hin 30
d s of the
day
he ini
nitia
ial trip
ial
trip
pd
de
ep
pos
sit dat
date
e and
an mus
m t insu
nsu
s re
su
e ful
fulll ttrip
fu
rip co
cost..
cost
Ava
aila
la
able
b for an addiiti
tional 50% of total base plan rate.
tio
For questions, quotes or to enroll,
visit www.travelexinsurance.com
or call 1-800-228-9792
3
State
Zip
Daytime Phone
Beneficiary Name
(Estate designated if left blank)
Primary Traveler Email
(Provide to receive Confirmation of Coverage via email)
Premium Calculation
Total Base Plan Rate
$
(calculate below for all travelers)
+ $
Primary Traveler
+ $
Second Traveler
+ $
Third Traveler
Trips 31-180 days in length
(include arrival and departure days)
x $8
x
# travelers
Optional Cancel for Any Reason Pakk
=
$
=
$
Fourth Traveler
# days over 30
(Base Plan + Extra Days x 50%)
Base Plan Total
Extra Days Total
$
$
Processing Fee
Total Amount Due
$
(and authorized as payment)
4
8.00
Enrollment Form
Enrollment Options
Please print clearly for accurate processing.
STM 0811
Travel Agent
Trip Details
Location Number / Agent Code
(on pg 7 of brochure)
Departure Date
/
MM
/
DD
Contact your local travel agent.
46-0032
Return Date
YYYY
MM
/
DD
/
YYYY
Internet
Country of Destination
Visit us at www.travelexinsurance.com to get a
quote, learn more or to purchase.
Tour Operator
Cruise Line
Airline
Phone
Traveler Details
YYYY
Trip Cost $
Speak with an experienced customer service
representative available at 1-800-228-9792,
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
Visa®
Daytime Phone
MasterCard®
Discover®
American Express®
Credit Card Number ___ ___ ___ ___ /___ ___ ___ ___ /___ ___ ___ ___ /___ ___ ___ ___
Beneficiary Name
(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
+ $
Third Traveler
Trips 31-180 days in length
(include arrival and departure days)
=
Fourth Traveler
x $8
x
# travelers
Optional Cancel for Any Reason Pakk
# days over 30
(Base Plan + Extra Days x 50%)
(Mandatory for all payment types)
Base Plan Total
=
$
Extra Days Total
$
$
Total Amount Due
$
4
Signature
$
Processing Fee
(and authorized as payment)
MM / YYYY
8.00
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.
If you wish to obtain a fraud statement specific to your state of residence, please
call 1-800-819-9004.
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