1. travel

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
Print Full Name
(As appears on credit card)
Any person who knowingly presents a false or fraudulent claim for payment of a loss or
benefit or knowingly presents false information in an application for insurance is guilty
of a crime and may be subject to fines and confinement in prison.
If you wish to obtain a fraud statement specific to your state of residence, please
call 1-800-819-9004.
Signature
(Mandatory for all payment types)
Date
MM
/
DD
/
YYYY
Plan fees are non-refundable after 10 day free look period.
5
Exclusions & Limitations
Meet Your Travel Needs
The following exclusion applies to the Medical Expense, Trip Cancellation, Trip Interruption,
and Trip Delay coverages:
We will not pay for loss or expense caused by or incurred resulting from a Pre-Existing
Condition, as defined in the plan, including death that results therefrom. This exclusion
does not apply to benefits under Medical Evacuation and Repatriation Benefits.
The following exclusion applies to the Accidental Death & Dismemberment coverage: We will
not pay for loss caused by or resulting from Sickness of any kind.
The following exclusions apply to all coverages: We will not pay for any loss under the
plan, caused by, or resulting from: suicide, attempted suicide, or intentionally self-inflicted
injury, while sane or insane (while sane in CO and MO); mental, nervous, or psychological
disorders (does not apply to Medical Expense Benefits); being under the influence of drugs
or intoxicants, unless prescribed by a physician; normal pregnancy or resulting childbirth
or elective abortion; participation as a professional in athletics; riding or driving in any
motor competition; declared or undeclared war, or any act of war; civil disorder (does not
apply to Trip Delay); service in the armed forces of any country; operating or learning to
operate any aircraft, as pilot or crew; mountain climbing, bungee cord jumping, skydiving,
parachuting, hang gliding, parasailing or travel on any air supported device, other than
on a regularly scheduled airline or air charter company; any criminal acts, committed
by you; a loss or damage caused by detention, confiscation or destruction by customs;
elective treatment and procedures; medical treatment during or arising from a covered
trip undertaken for the purpose or intent of securing medical treatment; a loss that results
from an illness, disease, or other condition, event or circumstance which occurs at a time
when the plan is not in effect for you.
Please refer to your Description of Coverage for Baggage/Baggage Delay and Rental Car
Damage exclusions.
DEFINITIONS: Pre-Existing Condition means an illness, disease, or other condition
during the 60 day period immediately prior to your effective date for which you or your
Traveling Companion, Domestic Partner, Business Partner or Family Member scheduled
or booked to travel with you: 1) received or received a recommendation for a diagnostic
test, examination, or medical treatment; or 2) took or received a prescription for drugs
or medicine. Item (2) of this definition does not apply to a condition which is treated or
controlled solely through the taking of prescription drugs or medicine and remains treated
or controlled without any adjustment or change in the required prescription throughout the
60 day period before coverage is effective under this Policy.
This plan provides insurance coverage for a covered trip. The purchase of travel insurance
is not required to purchase any other product or service from the travel retailer. You may
already have coverage that provides similar benefits and you may wish to compare the
terms of this coverage with your existing coverage. If you have questions about your
current coverage, call your insurer or agent. The travel retailer is not qualified to answer
questions about the benefits, exclusions or conditions of the travel insurance. Travelex
Insurance Services, Inc. 1121 North 102nd Court, Suite 202, Omaha, NE 68114. Toll free
1-800-228-9792. Email: [email protected]
California Residents: California Insurance Department: Toll free consumer hotline is
1-800-927-7357. Travelex CA Agency License #0D10209
New York Residents: The licensed producer represents the insurer for purposes of the sale.
Compensation paid to the producer may depend on the policy selected, the producers
expenses or volume of business. The purchaser may request and obtain information about
the producer’s compensation except as otherwise provided by law.
Travel Insurance is underwritten by Stonebridge Casualty Insurance Company a
Transamerica company, Columbus, Ohio; NAIC #10952 (all states except as otherwise
noted) under Policy/Certificate Form series TAHC5000. In CA, HI, NE, NH, PA, TN and TX
Policy/Certificate Form series TAHC5100 and TAHC5200. In IL, IN, KS, LA, OR, OH, VT, WA
and WY Policy Form Numbers TAHC5100IPS and TAHC5200IPS. Certain coverages are
under series TAHC6000 and TAHC7000.
This brochure is a brief summary of the program, please review the
Description of Coverage for an outline of benefits and amounts of coverage
available to you. Your Individual Policy or Group Certificate will govern the final
interpretation of any provision or claim. To view your state-filed form, please visit
www.travelexinsurance.com/SBPlans.aspx or call 1-800-819-9004 to obtain your Individual
Policy in the following states: IL, IN, KS, LA, OR, OH, VT, WA and WY or your Group Certificate for
all other states. © 2013 Travelex Insurance Services, Inc. 26232169A
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:
6
Travel Basic
Essential Travel Protection
Primary Coverage
Easy claims handling, less time and hassle to receive
reimbursement for eligible losses from us first, with no
deductibles, 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, plus $500 in
trip interruption coverage.
Ten Day Free Look
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.
Like us on Facebook!
facebook.com/TravelexInsurance
Please utilize the location number
and agent code below when
getting a quote or enrolling.
LOCATION NUMBER
AGENT CODE
COMPANY NAME
1013
7
STB 0811
STB 0811
Benefit Highlights
Benefits & Rates
Trip Cancellation & Interruption
Base Plan Benefits
Prrot
otec
ectt tr
trav
avel investm
men
ents and recover non-refundable,
prrepaid
d tr
trip
ip cos
osts
t iff a tr
trip is cancelled or interrupted due
to a covered
ed rea
easo
son.
n. Refer to the Description of Coverage
for details.
Trip Cancella
atio
on
100% of trip cost ($10,000 limit)
Trip Interruptio
ion
n
100% of trip cost ($10,000
(
limit)
•
•
•
•
•
•
•
•
Bagg
Ba
ggag
ge/
e Ba
aggage Delay
Sickness, Injury or Death
Financial Insolvency
Residence Uninhabitable
Trafficc Ac
Acci
ciide
cide
dent
n en Route
nt
Invo
In
vollunt
vo
luntaar
ary Em
Empl
ploy
pl
oyyme
oyme
m nt Ter
ermination/Transfer
Miililita
M
t ryy Dut
ta
utyy foor Na
Natu
turral
ral Di
D sa
saster
Deat
De
atth/
h/Ho
Hosp
Ho
spititaalizzat
sp
a io
ionn off Des
estititina
naatition
o Hos
on
ost
Common
Co
on Car
a ri
rier
er Canc
annce
cellllattio
ionns/Delayss
•
•
•
•
•
•
•
Weather
Strike
Quarantine
Hijack
ckin
inng
Jurry
Ju
ry Dut
uty
ty
Subpoena
Documented
Passport/Visa Theft
Reasons to Buy
Coverage Per Person†
Trip Delay
ay/M
/Misse
ed Cruise Connection
$500
$500 / $100
Emer
Em
e genc
cy Accident Medical Exp
pen
e se
$15,000
Em
mer
erg
gency Sickne
ness
ss Med
dical Expense
xp
p
$15,000
Eme
ergenc
er
gencyy Me
ge
Medi
d ca
al Evacuation/Re
epat
a ri
riat
atio
ion
n
$100
$1
00,0
,000
000
Trav
Tr
avel
av
el Ass
ssis
sista
tanc
anc
nce
e & Concierge*
Includ
clud
uded
ed
e
d
Traveling creates memories of a lifetime and
nd can
n alsso me
ean
encountering the unexpected. Travel Basic meet
meetss th
the
e
challenges of today’s travel for you to enjoy a wo
orry-frree
ee trip!
p!
Provid
Prov
des rei
e mb
mbur
u se
seme
men
nt for add
ddit
itio
i nall co
cost
stss such
such as
acco
ac
comm
mmod
od
dat
atio
ion
ns,, tr
t an
ansp
spo
ortation,, an
and me
eal
alss if a trip is
dela
de
laye
ed 5 hour
urss or
o more
e for a covvere
red
d re
reas
ason
on.
†
Location Number / Agent Code
Departure Date
• The cruise line for your trip decl
clar
cl
a es ban
ar
ankr
krup
uptc
tcyy
Country of Destination
• Yo
You haave
v a medical emergencyy during a shore excursion
Tour Operator
• A flflig
ight
ht delay causes you to miss a connection
Cruise Line
• Up
Upon
on arr
rrivval
a at yo
your
ur des
estitina
natition
on you
ourr lu
lugg
ggage is not foundd
$200,000
$35,
$3
5,00
000
Optional Upgrade
MM
/
DD
/
YYYY
Traveler Details
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
Birth Date
Base Plan Rates Per Person
MM
Use full cost per person,
include all non-refundable,
prepaid travel costs.
Ages
0-34
Ages
35-50
Ages
51-59
Ages
60-69
Ages
70-79
Ages
80+
$0
0 ex
exclud
exc
uddes
e tri
trip canc
trip
ancellat
ancell
ellllati
a on*
o *
on
$20
$25
$29
$29
$32
2
$36
$67
67
7
$500
$23
$31
$39
$45
$56
$88
Address
- $1,
$1 000
$31
$40
$49
$55
$76
$132
$13
2
City
Safe
Sa
fegu
fe
guar
ards
ar
d per
ds
erso
sona
so
n l ar
na
arti
t cl
ti
cles
es and exp
xpen
ense
en
se
es iff bag
agss ar
a e lo
ost
s,
s ol
st
olen
en,, da
en
dama
mage
ma
ged,
ge
d or de
d,
dela
laye
la
yed
ye
d fo
for 12
1 hou
ours
r or m
rs
mo
ore.
re
e.
$1,001 - $1,500
$40
$54
$58
$74
$96
$184
Daytime Phone
$1
$1,
1 501
50 - $2,0
2,000
00
$
$5
$53
$67
67
7
$7
$7
$76
$ 0
$10
$133
$13
3
$23
2 5
Beneficiary Name
Emergency Medical Expenses
$2,001 - $2,500
$68
$85
$95
$122
$162
$286
Prrov
ovid
id
des cov
over
errag
age
ge fo
f r em
emer
erge
er
genc
ge
ncy me
ncy
medi
dica
call tr
t ea
eatm
tm
ment
en
nt if
a sii ck
k ne
ness
ss or inju
i n ju
in
jury
u ry occ
cc ur
ccu
u r s wh
urs
whilil e tr
whi
trav
avel
av
elin
el
i g.
in
g
$ 50
$2
$2,
501
5
01
0 - $3,0
000
0
$81
$ 0
$10
$11
$1
12
$144
$144
$192
$19
2
$338
$33
8
$3,001 - $3,500
$101
$116
$134
$167
$264
$389
Emergency Medical Evacuation
$ 501
$3
$3,
50 - $4
4,0
000
0
$12
$
129
$145
5
$ 65
$1
$16
$18
188
1
$3
$30
$
300
$44
440
0
Prov
Pr
ovid
ov
ides
des cov
over
erag
er
ag
ge fo
or em
eme
mer
erge
genc
ncyy evvacua
nc
ac
cua
u ti
t on
on, iff nec
cesssa
ary
ry,
to
o the
he nea
e re
est
s qua
ualilifi
fiied
ed med
dic
cal
al fac
a illitt y, alsso in
ncl
c ud
u es
e
repa
re
p tr
pa
tria
ia
ati
tion
on..
on
$4,001 - $4,500
$143
$164
$193
$236
$334
$491
$1
Baggage & Baggage Delay
/
DD
$ 01
$5
-
$4,501
$4,
$4
50
501
01
1 - $5,0
5,, 00
0
$15
15
159
59
$181
$18
$1
$21
214
21
14
$ 4
$26
$37
$3
$370
$54
$54
41
Birth Date
MM
•
•
•
•
For
o rat
ates
e on tri
t p cost
stss abov
ovee $5,0
ov
, 0000 ple
p ase
see callll 11-8
-8000000-228
2 8-97
97792.
92
Maxi
x mum trip lenngth al
allow
owed
ow
edd 30
3 da
days.
An $8 proc
r ess
essing feee w
will
illl appply
ly peer plan
ly
l ; plan
la
lan
a s sold peer hous
hous
ou eeho
hold.
d
Rates are sub
u jec
ectt to
to chan
hang
ha
ange.
DD
/
DD
/
State
Transportation Pak
One
O
On
ne up
upgr
grad
gr
ade wi
with
ith two
wo gre
r at
at ben
enef
efit
ef
its!
it
s!! The
he pak
ak inc
ak
clu
lude
des
s
fllig
flig
ight
ght acc
cid
i en
entt c
co
ove
v ra
rage
age
e for
o eac
a h trav
travel
tr
av
vel
eler
er and
n renta
t l car
dama
da
mage
ma
g pro
r te
tect
c io
i n.
n
A ai
Av
a la
able
e fo
or an
n add
d it
itio
iona
io
nal $5
na
59 per plan
an
n.
Primary Traveler Email
(Provide to receive Confirmation of Coverage via email)
Premium Calculation
Total Base Plan Rate
$
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)
2
Zip
(Estate designated if left blank)
Primary Traveler
** Rec
Reeecceiv
eivee allll oth
eiv
other
her bas
basee plan
la beneffitss in
inclu
cludin
dingg $500
$500 in trip
ip iint
ip
inn errupt
ptio
pt
ion
on co
cover
verrage
ve
age.
/
Fourth Traveler Full Name
* Pro
Provid
vided
ed by Traavel
elex’
ex’
ex
x’s desi
s gna
gnated
ted as
assis
sistan
sis
ta ce pro
ta
tan
provid
vider.
e
1
Return Date
YYYY
Coverage is up to the limits shown per person. Limitations and exclusions apply.
Trip Cost
Incl
In
clud
cl
udes
ud
e s rei
es
eimb
mbur
mb
urse
ur
seme
se
me ntt for u nu
nuse
sed
d , n on-ref
refun
und
d abl
ble
expe
ex
p ns
pe
nses
ses
es and
d add
dit
itiio
iona
iona
al co
ost
sts su
such
uch as ac
acco
co
omm
mmod
odat
od
atio
at
ions
io
n ,
ns
tran
tr
ra
an
nsp
spor
o tati
or
tation
ta
on and
d mea
e lss if yyo
ou
urr con
onne
nne
nect
ctio
ct
ion
io
n iss mis
isse
sed
d by
by
3 ho
hour
u s or mor
ur
o e ffo
or a co
c vve
ered
re
ed re
ea
asson
on..
In
ncl
clud
u ess a wid
ud
de ra
rang
ng
ge of
o serrvi
vice
c s b
ce
be
efo
ore
re and
nd dur
urin
ing ttrrips
in
th
hro
r ug
ugh
h a 24
24/7
/7 tol
/7
o l fr
f ee
e num
umbe
er.
r Inc
clu
ude
dess as
a si
s st
stan
a ce
an
e witth
me
ediica
cal em
mer
erge
enc
n ie
ies,
s los
s,
st do
d cu
ume
ment
ntts or
o bag
aggage, evvent
en
n
tiick
cket
etin
et
ing,
g,, bus
usin
in
nes
e s se
serv
rvic
rv
ic
ces
es,, an
a d mu
m ch
c morre.
e
/
DD
Third Traveler Full Name
Missed Cruise Connection
Travel Assistance & Concierge*
/
MM
Airline
Birth Date
• Flight Accident AD&D (pe
(per person)
• Rental Carr Damag
D
ge Protectio
ion
n (pe
perr plan
plan))
STB 0811
TAHC5001GES
Trip Details
• You or a family member become ill an
a d yo
y u ca
cann no lon
onge
g r tr
t avel
Transportation Pak
Trip Delay
Please print clearly for accurate processing.
(on pg 7 of brochure)
• Yo
Youu lo
l se your pa
p ss
s port and need assistance too re
retu
turn
rn hom
me
Optional Upgrades
Enrollment Form
4
8.00
Enrollment Form
Enrollment Options
Please print clearly for accurate processing.
STB 0811
TAHC5001GES
Travel Agent
Trip Details
Contact your local travel agent.
Location Number / Agent Code
(on pg 7 of brochure)
Departure Date
/
MM
/
DD
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
Airline
Cruise Line
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
Visa®
MasterCard®
Discover®
American Express®
Beneficiary Name
Credit Card Number ___ ___ ___ ___ /___ ___ ___ ___ /___ ___ ___ ___ /___ ___ ___ ___
(Estate designated if left blank)
Credit Card Expiration Date
Primary Traveler Email
(Provide to receive Confirmation of Coverage via email)
Print Full Name
(As appears on credit card)
Premium Calculation
Total Base Plan Rate
$
Any person who knowingly presents a false or fraudulent claim for payment of a loss or
benefit or knowingly presents false information in an application for insurance is guilty
of a crime and may be subject to fines and confinement in prison.
(calculate below for all travelers)
+ $
Primary Traveler
+ $
Second Traveler
Optional Transportation Pakk
MM / YYYY
+ $
Third Traveler
Fourth Traveler
=
$
Base Plan Total
$
($59)
Processing Fee
$
Total Amount Due
$
(and authorized as payment)
4
If you wish to obtain a fraud statement specific to your state of residence, please
call 1-800-819-9004.
Signature
8.00
(Mandatory for all payment types)
Date
MM
/
DD
/
YYYY
Plan fees are non-refundable after 10 day free look period.
5