Insurance Travel Renewal Declaration

INSURANCE TRAVEL RENEWAL DECLARATION

Applicant Name:   Policy Number:

Applicant / Insured Information

Policy Renewal Details

Renewal Effective Date:   Previous Policy Period: From to

Coverage Options (select all that apply)

  Emergency Medical Expenses

  Medical Evacuation and Repatriation

  Baggage and Personal Effects

  Trip Cancellation and Interruption

  Trip Delay Benefits

  Rental Car Damage Protection

  Accidental Death & Dismemberment

Travel Details

Trip Start Date:   Trip End Date:

Medical and Eligibility Declarations

Have there been any changes to your health, medications, or treatment since the last policy period?    Yes    No

I declare that I am a lawful resident of the jurisdiction in which this renewal is submitted and that I meet any residency requirements specified under the policy.  Acknowledge

Beneficiary Designation (if applicable)

Exclusions, Limitations and Endorsements

The policy includes exclusions for: pre-existing medical conditions not declared, participation in hazardous activities where coverage is excluded, acts of declared war, and losses arising from the insured’s illegal acts. The insured acknowledges receipt of, and agrees to be bound by, the policy exclusions and limitations stated in the master policy document.

I acknowledge that I have read and understand the standard exclusions and limitations of coverage.  Acknowledge

Required Documentation Checklist

  Copy of passport or travel document

  Trip itinerary / booking confirmation

  Medical records or physician statement (if required)

  Proof of premium payment

Declaration and Certification

By signing below I certify, under penalty of perjury, that the information provided in this Insurance Travel Renewal Declaration is true, complete and accurate to the best of my knowledge. I understand that any material misrepresentation or omission may result in denial of coverage, rescission of the policy, or adjustment of benefits.

I authorize the insurer and its representatives to obtain and disclose medical and travel-related information about me to the extent necessary to underwrite the policy, adjust claims, or comply with applicable law. I consent to the release of such information to and from health care providers, other insurers, and claim administrators when relevant to coverage or claims.

I acknowledge that renewal of coverage is subject to payment of the renewal premium and underwriting approval. I agree to promptly notify the insurer of any change in my travel plans, health status, or other circumstances that may affect coverage.

Fraud Warning: Providing false or misleading information to obtain insurance coverage or benefits is a criminal offense under applicable law and may subject the claimant to penalties, policy denial, or coverage rescission.

Acknowledgement of Terms

I have read and understand the terms and conditions of the policy as it applies upon renewal. I accept responsibility for payment of the renewal premium and agree that coverage will be governed by the terms of the applicable policy documentation.

Sign Now