Insurance Travel Application

INSURANCE TRAVEL APPLICATION

Applicant Information

Client Name:

Date of Birth:    Passport Number (if applicable):

Travel Details

Departure Date:    Return Date:    Purpose of Travel:

Policy and Coverage Requested

Policy Type: Single Trip Annual Multi-Trip Cruise Business Travel

Proposed Policy Period From:    To:

Coverage Options (select desired coverages)

Trip Cancellation
Trip Interruption
Emergency Medical Expenses
Emergency Medical Evacuation
Baggage Loss/Delay
Accidental Death & Dismemberment
Personal Liability
Rental Car Damage

Medical History & Pre-existing Conditions

Do any travelers have pre-existing medical conditions? Yes No

Is any traveler currently pregnant? Yes No

Will any traveler engage in hazardous activities (e.g. scuba diving, skydiving, mountaineering)? Scuba Diving Skydiving Mountaineering

Beneficiary Designation (for Accidental Death Benefit)

Exclusions and Important Notices

The policy will contain exclusions and limitations. Typical exclusions include loss or injury resulting from: acts of war or civil unrest; intentionally self-inflicted injury; participation in illegal acts; routine pre-existing medical conditions when not covered under the policy terms; participation in professional competitive sports; loss resulting from failure to follow local health requirements; and losses arising from intoxication or controlled substance use not prescribed by a physician.

Fraud Warning: Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against the insurer, submits an application or files a claim containing a false statement or omission may be subject to civil or criminal penalties under applicable law.

Premium Payment and Authorization

Preferred Payment Method: Credit Card Bank Transfer Check

By selecting the authorization box below and signing this application, the applicant authorizes the insurer or its authorized agent to charge or arrange payment for the premium in accordance with the method selected, and acknowledges that coverage is subject to receipt and acceptance of premium and issuance of a policy or certificate.

I authorize premium payment and agree to billing as indicated above.

Declaration and Certification

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that omission or misrepresentation of material facts may result in denial of coverage, rescission, or refusal to pay claims. I authorize any physician, medical practitioner, hospital, clinic, insurance company, or other organization to release to the insurer any information concerning medical history, treatment or benefits for the purpose of underwriting and claims administration. I understand that this authorization remains valid for the duration needed to underwrite and administer claims.

I acknowledge receipt of the policy terms, conditions, and exclusions when the policy or certificate is issued, and agree that the policy issued, if any, shall constitute the entire contract between the parties.

I have read, understand, and accept the statements above.

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