Insurance Journey Application

Insurance Journey Application

Applicant / Insured Information

Proposed Policy Details

Policy Type: Travel Insurance Personal Accident Emergency Medical Comprehensive Journey

Policy Period: From to

Coverage Selection

Select desired coverages (tick all that apply). For coverages with specified limits, enter the requested limit adjacent to the checkbox.

Trip Cancellation and Interruption — Limit: $

Emergency Medical Expense — Limit: $

Baggage Loss / Delay — Limit: $

Emergency Evacuation and Repatriation

Travel Delay / Missed Connection — Benefit $

Exclusions and Limits

The policy will contain specific exclusions. Typical exclusions include, but are not limited to: loss or expense resulting from intentional self-injury, participation in professional sports, routine dental treatment, pre-existing medical conditions not disclosed and accepted by the Company, unlawful acts, war, civil commotion, and losses covered by other valid insurance. Coverage limits, sub-limits and aggregate maximums stated in the policy apply.

I acknowledge that I have read and understand the exclusions and limits that will be set forth in the issued policy and that coverage will be subject to all policy terms, conditions, exclusions and endorsements.

Prior Insurance / Claims History

In the last five years, have you had any travel or personal insurance cancelled, declined, or had a claim paid?

Beneficiary Designation

Designate beneficiaries to receive applicable policy proceeds in the event of a covered loss resulting in death or payee benefits.

Declarations, Authorizations and Fraud Warning

By signing below I certify that the information provided in this Insurance Journey Application is true and complete to the best of my knowledge. I understand that any material misstatement or omission may result in denial of benefits, rescission of coverage, or other remedies available to the Company.

I authorize the insurer and its representatives to verify any information provided herein, including obtaining records from employers, medical providers, other insurers, or consumer reporting agencies as necessary to underwrite and administer coverage. I further authorize any person or organization to release information requested in connection with this application. A photocopy or electronic reproduction of this authorization shall be as valid as the original.

I acknowledge that coverage will not be in effect until accepted and issued by the insurer, and any premium payment required is received and applied in accordance with the insurer's underwriting rules. Coverage is subject to the terms, conditions, exclusions and endorsements of the issued policy.

Fraud Warning: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or claim containing materially false information may be subject to civil and criminal penalties, including denial of coverage and recovery of amounts paid.

Additional Information

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