Insurance Travel Declaration

INSURANCE TRAVEL DECLARATION

Applicant / Insured Information

Date of Birth:    Phone:    Email:

Policy Details

Coverage Amount:    Deductible:    Premium:

Policy Period From:    To:

Travel Information

Trip Start Date:    Trip End Date:

Do you have any pre-existing medical conditions to declare? Yes No

Coverage Selection

Select coverages to be in effect for this trip:

Emergency Medical Expenses

Emergency Medical Evacuation and Repatriation

Trip Cancellation

Trip Interruption

Baggage Loss / Delay

Accidental Death & Dismemberment

Personal Liability (while traveling)

Exclusions & Important Notices

The following are typical exclusions to coverages under this declaration. Coverage will not apply for loss, injury or expense resulting from:

• Intentional self-harm, suicide or attempted suicide.
• Losses arising from participation in professional or organized competitive sports, unless specifically endorsed.
• War, invasion, hostilities (whether war be declared or not), civil war, rebellion, revolution, insurrection.
• Loss arising from the insured's commission of or attempt to commit a criminal act.
• Any claim arising directly or indirectly from a known pandemic, epidemic, quarantine, or government travel restriction, unless specifically endorsed.
• Pre-existing conditions not declared where disclosure was required by the policy terms.

I acknowledge that I have read and understand the exclusions above and that coverage is subject to all policy terms, conditions, limitations and endorsements. Acknowledged

Beneficiary Information

Relationship:    Percentage:

Relationship:    Percentage:

Declarations and Certifications

By signing this Insurance Travel Declaration, I represent and warrant that all statements contained herein are true, complete and accurate to the best of my knowledge. I agree that this declaration, together with the referenced policy terms, endorsements and applications, constitute the entire agreement between me and the insurer with respect to the coverages selected.

I authorize the disclosure of any medical or travel-related records to the insurer and its agents for the purpose of underwriting, claim handling and fraud investigation. I understand that failure to disclose material facts, including pre-existing medical conditions or prior claims, may result in denial of coverage or rescission of the policy.

I acknowledge that coverage for certain situations may require pre-authorization from the insurer. I agree to cooperate with reasonable requests for information and to provide documentation supporting any claim. I further understand that the insurer may seek recovery from responsible third parties for amounts paid on my behalf (subrogation) and I agree to cooperate with such recovery efforts.

Fraud Warning: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing materially false information may be guilty of insurance fraud and subject to civil and criminal penalties under applicable law.

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