Insurance Travelers Application

INSURANCE TRAVELERS APPLICATION

Applicant / Insured Information

Trip Details

Business Leisure Study Other (explain below)

Policy Details & Coverage Selections

Single‑Trip Annual / Multi‑Trip

Select coverage options to be included in this policy. Coverage is subject to policy terms, conditions, limits and exclusions set forth below.

Beneficiary Designation (for AD&D death benefit)

Designate primary beneficiary(ies). Percentages must total 100% for primary beneficiaries. If no primary beneficiary survives, pay to contingent beneficiary(ies) as indicated.

Medical Information & Pre‑Existing Condition Questions

You must answer the following questions. Failure to disclose medical information may result in denial of coverage and rescission of the policy.

Yes No

Yes No

Exclusions, Limitations & Important Notices

The policy contains exclusions and limitations, including but not limited to: loss or expense resulting from an insured's intentional acts, suicide or attempted suicide, participation in unlawful acts, participation in high‑risk activities unless specifically endorsed, losses due to declared or undeclared war, travel against government travel advisories, and losses related to pre‑existing medical conditions except as provided by a separate pre‑existing condition waiver. Coverage for certain benefits is limited to the amounts shown in the policy schedule and subject to deductible and waiting periods where applicable.

Any coverage for pre‑existing conditions, CFAR endorsements, or hazardous activities must be expressly requested and may require additional premium, underwriting approval, and compliance with specified conditions. Applicants acknowledge that purchase of coverage after payment of non‑refundable trip deposits may be required to preserve certain benefits; late purchase may void some coverages.

Declarations, Authorizations & Fraud Warning

By signing below, the applicant declares that the information provided in this application is true, complete and correctly recorded to the best of the applicant's knowledge. Applicant authorizes the insurer and its representatives to obtain medical records, travel records and other relevant information to underwrite, investigate or adjust claims. Applicant understands that the insurer may rely on third‑party data sources and that intentional misrepresentation or omission of material information may constitute fraud and may result in denial of coverage, rescission of the policy, or other remedies permitted by law.

Applicant acknowledges receipt of the policy terms and conditions upon issuance, including cancellation and refund provisions. Cancellation of coverage after effective date may be subject to a pro rata refund of premium less administrative fees and any benefits already paid. The insurer expressly reserves all rights of subrogation and payment on behalf of the insured where applicable.

Applicant Certification & Signature

I certify under penalty of perjury that the answers and statements contained in this application are true and complete. I understand that this application, together with any required premium payment and documentation, will form the basis of any policy issued. I acknowledge that coverage does not become effective until accepted and confirmed by the insurer in writing and any required premium has been received.

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