Enrollment Options Travel Agent Contact your local travel agent. Internet Visit us at www.travelexinsurance.com to get a quote, learn more or to purchase. Phone Speak with an experienced customer service representative available at 1-800-228-9792, M-F 8:00 am to 7:00 pm CST, to answer questions, receive a quote or to enroll. Fax or Mail Fax both sides of enrollment form to 1-800-867-9531 or mail to: Travelex Insurance Services, PO Box 641070, Omaha, NE 68164-7070. Payment Details Check or Money Order (payable to Travelex Insurance Services) Visa® MasterCard® Discover® American Express® Credit Card Number ___ ___ ___ ___ /___ ___ ___ ___ /___ ___ ___ ___ /___ ___ ___ ___ Credit Card Expiration Date MM / YYYY (As appears on credit card) Signature (Mandatory for all payment types) MM / DD / Meet Your Travel Needs The following exclusions apply to Trip Cancellation & Trip Interruption, Trip Delay, Missed Connection, Emergency Accident & Sickness Medical Expense, Emergency Evacuation & Repatriation of Remains, and Optional Flight Accidental Death & Dismemberment. Loss caused by or resulting from: Before you leave home, consider the unexpected. It’s important to protect you and your trip investment in today’s travel environment. Meet your essential travel needs with our value-driven plan and find the peace of mind your trip deserves with these important plan highlights: Pre-Existing Conditions, as defined in the Definitions section (except Emergency Evacuation and Repatriation of Remains); Suicide, attempted suicide or any intentionally self-inflicted injury while sane or insane (in Missouri, sane only) unless results in the death of a non-traveling immediate Family Member; War, invasion, acts of foreign enemies, hostilities between nations (whether declared or not), civil war; Participation in any military maneuver or training exercise; Piloting or learning to pilot or acting as a member of the crew of any aircraft; Mental or emotional disorders, unless hospitalized; Participation as a professional in athletics; Participation in underwater activities (does not include recreational swimming); Being under the influence of drugs or intoxicants, unless prescribed by a Physician or unless results in the death of a non-traveling immediate Family Member; Commission or the attempt to commit a criminal act; Participating in bodily contact sports; skydiving; hang-gliding; parachuting; mountaineering; any race; bungee cord jumping; and speed contest (speed contest shall not include any of the regatta races); scuba diving if the depth exceeds 50 feet (unless accompanied by a dive master and unless the Insured is certified to dive); spelunking or caving; heliskiing or extreme skiing. Exclusion does not apply to Trip Cancellation. Bodily contact sports means any sport where the objective is to physically render an opponent unable to continue with the competition such as boxing and full contact karate; Dental treatment except as a result of an injury to sound natural teeth limited to $750; Any non-emergency treatment or surgery, routine physical examinations, hearing aids, eyeglasses or contact lenses; Pregnancy and childbirth (except for complications of pregnancy) except if hospitalized; Traveling for the purpose of securing medical treatment; Services not shown as covered; Directly or indirectly, the actual, alleged or threatened discharge, dispersal, seepage, migration, escape, release or exposure to any hazardous biological, chemical, nuclear radioactive material, gas, matter or contamination; Care or treatment that is not medically necessary; Injury or Sickness when traveling against the advice of a Physician; Cosmetic surgery except for: reconstructive surgery incidental to or following surgery for trauma, or infection or other covered disease of the part of the body reconstructed, or to treat a congenital malformation of a child. Some exclusions may not be valid or wording may differ in your state of residence. For full details, please consult the Certificate of Insurance at www.travelexinsurance.com or call 1-800-228-9792. Travel Basic Essential Travel Protection Primary Coverage Receive reimbursement for your eligible losses from Travelex first, with no deductibles, and before any other collectible insurance. Post Departure Protection Select the $0 trip cost level if you don’t need cancellation coverage. Receive all other base plan benefits, including $500 in trip interruption coverage. Satisfaction Guarantee If you are not completely satisfied within 10 days of purchasing this plan, Travelex will refund your premium cost, if you have not departed on your trip or filed a claim. Open to Page 3 for More Reasons to Protect You and Your Trip Investment! Please refer to the Certificate of Insurance for Baggage/Baggage Delay and Optional Collision Damage Waiver exclusions. Print Full Name Date Exclusions & Limitations YYYY Plan fees are non-refundable after 10 day review period. DEFINITIONS: Pre-Existing Condition means any injury, sickness or condition of You, or Your Traveling Companion for which within the sixty (60) day period prior to the Effective Date of Trip Cancellation coverage under the Policy (a) first manifested itself or exhibited symptoms which would have caused one to seek diagnosis, care or treatment; (b) required taking prescribed drugs or medicine, unless the condition for which the prescribed drug or medicine is taken remains controlled without any change in the required prescription; or (c) required medical treatment or treatment was recommended by a Physician. Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and/or civil penalties. If you wish to obtain a fraud statement specific to your state of residence, please call 1-800-819-9004. Underwritten by Nationwide Mutual Insurance Company and affiliated companies. Certain states underwritten by United States Fire Insurance Company. This product may not be available to residents of all states. This brochure is a partial description of benefits. Certain terms, conditions, exclusions and limitations apply. Please visit our website at www.travelexinsurance.com and refer to the Certificate of Insurance for full details. © 2010 Travelex Insurance Services, Inc. 5 6 Please reference the following when enrolling: LOCATION NUMBER AGENT CODE 05-0804 COMPANY NAME Adventure International 7 MTB 0710 MTB 0710 Benefit Highlights Benefits & Rates Trip Cancellation & Interruption Base Plan Benefits Pro tects Protec ts tra tr vel invess tme tm nts if a trip is cancelled or intterrupt pted. ed. Re Recov c er no non-refundable, prepaid trip costs for the folll owi owing ng cov covered reasons: Trip Cancella at o ation 100% of trip cost ($10,000 limit) Trip Interruptiion 100% of trip cost ($10,000 ( limit) • • • • • • • Sickness, Accidental Injury or Death Bankruptcy/Default Residence Uninhabitable Traffic icc Ac Accident en Route Emplooym Empl ymen eent ntt Termi Teer nation/Transfer Felo Felonio eloonio niouus us A Ass ssau aultt aul Deat e hh// Hosp ea ospita itt liliz izat ation on of of Des Destin tinati ation on Hos ostt • • • • • • • Weather Strike Quarantine Hijacking Jury ury Duuty Subpoen b oen e a en Burglary Reasons to Buy Coverage Per Person Trip Dela ay/M y/Missed e Connection $500 Baggag Bag gage/B e ag aggage Delay $500 / $100 Emergency Eme cy Accident Medical Exp pens e e $15,000 Em merg merg gency Sickn ness Medi Medical Expense Exp xp p $15,000 Eme ergency rge g ncy M Me edic d all Evacuation/Re ep pa atri t ati ation on $10 1 0,0 0,000 000 Travvel Tra vel As Asssistan sista an nce e & Concierge Inclu Inc nclud ude ed ed Location Number / Agent Code ($1 million maximum pla plan lim mit) $35,000 000 • Collision C n Dam Damage age Waiver (per er pla plan) n) • Roadside Assistance ce (pe (per pla an) / Departure Date • The cruise line for your trip decl clare ar s ba are bankrup ank ptcy Country of Destination • You hav ave a medical emergency du during a shore excursion Tour Operator • A flfligh ightt delay d causes you to miss a connection Cruise Line • Upon arriv aarriv rival a att you yourr dest destina inatio tionn your your lu lugga ggage is not found Optional Upgrade Included MM / DD Return Date YYYY / DD / YYYY Airline Primary Traveler Full Name MM / / YYYY Trip Cost $ / YYYY Trip Cost $ / YYYY Trip Cost $ YYYY Trip Cost $ DD Second Traveler Full Name Birth Date MM / DD Third Traveler Full Name Missed Connection Includ ud des reii mburse s men entt ffor or unu nused sed,, nonnon-ref refund ndabl able e ex ens exp enses es and addition onal al cos c ts suc such h as as acco accommo m dat mm d tion da ions, s, transp transp tra sp port o ati ation tiion and me m als if yo your u con ur co nection n is is miss missed ed by 3h hour ourss o our orr m more ore re e fo fforr a c cover ered ed rea re son so . Birth Date Base Plan Rates Per Person Trip Cost Ages 0-34 Ages 35-50 Ages 51-59 Ages 60-69 Ages 70-79 Ages 80+ $16 6 $21 $ $25 $ $27 $ $29 $52 $500 $19 $27 $36 $40 $49 $69 - $1,0 $1,000 00 $ $27 $36 $ $44 $5 $50 $6 $69 $106 10 $1,001 - $1,500 $36 $50 $53 $68 $89 $177 $1,5 $1,5 501 0 - $2,00 $2,00 2 00 00 $48 $48 $62 $62 $70 $93 9 $126 $228 Provid Pro rovid vides es cov overa erage era ge g e for o e or emerg ergenc enc ency n y medi medi edical cal tr treat eatmen eat mentt if men if a sick sick i knes nesss or nes or inju inju u ry y occ oc urs wh while ile ttrrave av lilin ave li ng. g g. $2,001 - $2,500 $62 $79 $88 $115 $155 $279 $2,5 $2 5 501 0 - $3,000 01 3 00 3,00 0 0 $74 74 $93 $105 $137 $185 $331 1 Emergency Medical Evacuation $3,001 - $3,500 $94 $109 $127 $160 $257 $382 $3 5 $3,501 - $4,00 4,00 0 0 $122 12 $1 $138 138 $ 58 $158 $181 181 $293 $293 $43 $433 $4 4 3 $4,001 - $4,500 $136 $157 $186 $229 $327 $484 $4,5 4 501 1 - $5,00 , 00 $152 152 52 $174 174 $207 20 07 $2 $25 $257 $363 $3 36 $5 $534 $ 534 534 (use full cost per person) $0 0 eexclu excl x des trip trripp cancel cancel cellatio latio ti n* n Baggage & Baggage Delay $1 Sa egu Saf eguard a s pers ard pers ersona ona na al arti arti rticle cle cles l s and exp expens enses ens e if bag es gs are los st, stolen sto len len, en, dama dama maged g , or ged or dela dela el yed ffo or 1 12 2 hour hour o s or or m more ore ore. re. $501 $501 Emergency Medical Expenses P vid Pr Pro vides e co es cov cov overa era rage ge for ge for emerg em mer erg rg genc enc n cy e evac vac cuat a ion at on, if nece on ecessa s ry, ssa t the n to neare est s q qua alif lified ified ed d me medic dic d i all fac cili ilil tty ty, y, y a also o includ inc nc clud ud dess re atr rep atriat iation iat a ion at io on. o - Travel Assistance & Concierge * Rece Receive ecceive ve all all othe other theer bbase se plan laaan benefits i includi including ng $500 $500 in tripp inte nnte t rruption ion o cov on coverag oveerag a e. In Inc nclud u ess a wide de e ra range of sservi r cess be rv b for fo oe a and nd dur du ing ing g tr trips ips ip ips thr h oug gh a 24 24/7 / to /7 tolll fre tol ree ee nu e numbe mberr. Inc mbe I lud ud des e as ass s ist i anc is ce with med m dica call emer ca me gen g cie ge ies, s los s, os o st docu oc o c cumen ume men e ts ts or o bag b gag ga a e, e event tic icket cket keting ke ing ng g, bus usi sines sines ne s serv serv ervice ice ces, s,, and and m much mor m e. e • • • • Fo For raates te on trip cost costss above above ov $$5,0 , 0000 pleas easse ccall 1-800-228 -800 800 000-2 -228-979 979 7 2. 79 2 Maximu x m trip lengt ngthh allowe al oweed 30 3 da days. An $88 proc r essi ess ngg feee w will illl appl apply pe perr pl p an. Ra are subj Rates u ec ect to chang chang ha ge. MM / DD Fourth Traveler Full Name Birth Date MM / DD / Address City State 2 Zip Daytime Phone Beneficiary Name (Estate designated if left blank) Transportation Pak One upgr One pg g ad ade d with th tthr hree g gre re be reat rea ben en nefit efits! s! T The he pak h ak inclu cludes es flig flight ht acc acci ccident c de c coverag a e ffor ea e ch h trave ave v ler and nd d 24 24 h hour u road o side as stan assi sta a ce with th a c collis i ion i damage ge w waive aiv r fo aive or re rental nta ntal t veh v icles. Ava A aila able e forr addi dditio iional n $ na $5 59 9 per pe plan. Primary Traveler Email (Provide to receive Confirmation of Coverage via email) Premium Calculation Total Base Plan Rate $ Primary Traveler For questions, quotes or to enroll, visit www.travelexinsurance.com or call 1-800-228-9792 (calculate below for all travelers) + $ + $ Second Traveler Optional Transportation Pakk + $ Third Traveler 3 Fourth Traveler = $ Base Plan Total $ ($59) Processing Fee $ Total Amount Due $ (and authorized as payment) 1 MM Traveler Details Birth Date $200,000 • Flight Accident AD&D (per (p person) MTB 0710 Trip Details (on pg 7 of brochure) Transportation Pak Re mbu Rei m rsess for f reasonabl ab e acco abl ccomm m da mmo dat ation at ions, tra ions, transportation and nd me meals if a tri meals trip p is delayed yed 5 hou hours rs or mor ore e for f a cov o ere ered d rea eason. eas on on. Please print clearly for accurate processing. • You or a family member become ill and an yyou can no lon onger ge trravel • Yoou los lo e youur pa passp s ort and need assistance to ret ss return urn ho home mee Optional Upgrades Trip Delay Traveling creates memories of a lifetim time e, and can can also l mean encountering the unexpected. Travel Basic cm meet eetts the challenges of today’s travel for you to enjoy a wo orry-fre re ee trip p! Enrollment Form 4 8.00 Enrollment Form Enrollment Options Please print clearly for accurate processing. MTB 0710 Travel Agent Trip Details Location Number / Agent Code (on pg 7 of brochure) Departure Date / MM / DD Contact your local travel agent. 05-0804 Return Date YYYY MM / DD / Internet YYYY Visit us at www.travelexinsurance.com to get a quote, learn more or to purchase. Country of Destination Tour Operator Cruise Line Airline Phone Traveler Details YYYY Trip Cost $ Speak with an experienced customer service representative available at 1-800-228-9792, M-F 8:00 am to 7:00 pm CST, to answer questions, receive a quote or to enroll. YYYY Trip Cost $ Fax or Mail YYYY Trip Cost $ Fax both sides of enrollment form to 1-800-867-9531 or mail to: Travelex Insurance Services, PO Box 641070, Omaha, NE 68164-7070. YYYY Trip Cost $ Primary Traveler Full Name Birth Date MM / / DD Second Traveler Full Name Birth Date MM / DD / Third Traveler Full Name Birth Date MM / DD / Fourth Traveler Full Name Birth Date MM / DD / Payment Details Address City State Check or Money Order (payable to Travelex Insurance Services) Zip Daytime Phone (Estate designated if left blank) Credit Card Expiration Date Primary Traveler Email (Provide to receive Confirmation of Coverage via email) $ American Express® Print Full Name (calculate below for all travelers) + $ + $ Second Traveler Optional Transportation Pak MM / YYYY (As appears on credit card) Premium Calculation Total Base Plan Rate Discover® Credit Card Number ___ ___ ___ ___ /___ ___ ___ ___ /___ ___ ___ ___ /___ ___ ___ ___ Beneficiary Name Primary Traveler MasterCard® Visa® Signature + $ Third Traveler Fourth Traveler = (Mandatory for all payment types) $ Base Plan Total Processing Fee $ Total Amount Due $ (and authorized as payment) 4 MM / DD / YYYY Plan fees are non-refundable after 10 day review period. $ ($59) Date 8.00 Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and/or civil penalties. If you wish to obtain a fraud statement specific to your state of residence, please call 1-800-819-9004. 5