Insurance Travelers EOI Form

INSURANCE TRAVELERS EOI FORM

Applicant / Insured Information

Date of birth:    Gender:

Policy and Trip Details

Trip start date:    Trip end date:

Trip purpose: Leisure Business Study Other

Coverage Requested & Premium

Please indicate the coverage types requested (check all that apply).

Trip Cancellation
Trip Interruption
Emergency Medical Coverage
Medical Evacuation / Repatriation
Accidental Death & Dismemberment
Baggage Loss/Delay

Medical History — Required

Answer each question honestly. Failure to disclose material medical information may result in denial or rescission of coverage. For each question, check Yes or No. If Yes, provide details in the corresponding explanation field.

1. In the past 12 months have you been hospitalized or had surgery?   Yes No

2. In the past 5 years have you been diagnosed or treated for heart disease, stroke, cancer, diabetes, or chronic lung disease?   Yes No

3. Are you currently under medical treatment, receiving therapy, or awaiting tests/results?   Yes No

4. Do you take any prescription medications on a regular basis?   Yes No

5. Within the last 5 years have you been treated for or advised you have a mental health condition, substance abuse, or dependence?   Yes No

6. Are you currently pregnant or attempting to become pregnant?   Yes No

7. Do you consider yourself currently fit to travel and participate in the activities planned?   Yes No

Medical Provider / Records

Date last seen by physician:

Travel Activities / Hazardous Pursuits

Will you engage in any hazardous activities during the trip such as scuba diving, mountaineering, heli-skiing, base jumping, or professional/competitive sporting events?   Yes No

Beneficiary Designation

Exclusions and Underwriting Notice

The policy for which this Evidence of Insurability is submitted may exclude loss resulting from pre-existing medical conditions, hazardous activities, intentionally self-inflicted injury, active participation in war or insurrection, commission of a criminal act, or loss sustained while impaired by alcohol or drugs. Coverage is subject to underwriting review and may be modified, conditioned, or declined based on medical information and other risk factors. Benefits applicable to accidental death, dismemberment, and medical evacuation are subject to the specific terms, limits, and exclusions of the policy.

Authorization and Certification

By signing below I certify that the statements and answers provided on this form are complete and true to the best of my knowledge. I understand that any material misrepresentation or omission may result in denial of coverage or rescission of the policy. I authorize any physician, medical practitioner, hospital, clinic or other medical facility, insurer, or consumer reporting agency to release to the insurer and its representatives any information concerning medical history, treatment, diagnosis, consultations, or other relevant facts for purposes of underwriting and claims adjudication. This authorization is valid for the period necessary to obtain such information but no longer than permitted by law.

I authorize the insurer to obtain and disclose relevant information to third-party administrators, reinsurers, or providers performing underwriting and claim services. I understand a photocopy or electronic reproduction of this authorization shall be as valid as the original.

I acknowledge that the information provided is true and complete and that I have read and understand the statements above.

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