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 MasterCard® Discover® American Express® Credit Card Number ___ ___ ___ ___ /___ ___ ___ ___ /___ ___ ___ ___ /___ ___ ___ ___ Credit Card Expiration Date MM / YYYY Print Full Name (As appears on credit card) Signature MM / DD / 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. 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: 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. 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. 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. (Mandatory for all payment types) Date Meet Your Travel Needs Travel Basic Essential Travel Protection M ad e E a s y 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. Please refer to your Description of Coverage for Baggage/Baggage Delay and Rental Car Damage exclusions. Check or Money Order (payable to Travelex Insurance Services) Visa® Exclusions & Limitations YYYY Plan fees are non-refundable after 10 day free look period. If you wish to obtain a fraud statement specific to your state of residence, please call 1-800-819-9004. 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 statefiled 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. © 2011 Travelex Insurance Services, Inc. 25523627 5 6 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. 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 1211 7 STB 0811 STB 0811 Benefit Highlights Benefits & Rates Trip Cancellation & Interruption Base Plan Benefits Protects Protec ts tra tr vel invesstme tm nts if a trip is cancelled or intterrupt upted. ed. Re Recov co er non non-refundable, prepaid trip costs for the followin ing g cove covered red reasons. Refer to the Description of Coverage for compl mp ete t details. Trip Cancella at o ation 100% of trip cost ($10,000 limit) Trip Interruptiion 100% of trip cost ($10,000 ( limit) • • • • • • • • Baggag Bag gage/B e ag aggage Delay Sickness, Injury or Death Financial Insolvency Residence Uninhabitable Trafficc Ac Accid cident cid e en Route en ent Invvolunt In olu l ntaary Empploy loymen m t Term me Termination/Transfer M Mili ilitar ili t yD tar Duty uty foor Natu Natura rraal al Di D sas sa ter Deaath/Hos De th/Hos Hospit pitaalizat pit lizat za ion off Deesti stinat nation nat ion Ho Host st Common on Car Ca rie rierr Cance anc ncellati ell tion ons/Delayss • • • • • • • Weather Strike Quarantine Hijacki cking ng Jury Du Duty tyy Subpoena Documented Passport/Visa Theft Reasons to Buy Coverage Per Person Trip Dela ay/M y/Missed e Cruise Connection $500 $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 Me Medic 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* Inc nclud lud uded ed e d Traveling creates memories of a lifetime and nd can also so me ean encountering the unexpected. Travel Basic meets me ts s the challenges of today’s travel for you to enjoy a wo orry-fre re ee trip p! Provid Prov des rei re mbu mburse semen mentt for f additi add itionall c cost o s such as ost accomm acc ommoda od datio tions ns,, tr t ans anspo portation,, an and mea eals ls if a trip is de aye del ed 5 hours urs or o mo more re for a cov vere red d reas e on on. Location Number / Agent Code Departure Date • The cruise line for your trip decl clare cl a s bank are bankrup uptcy tcy Country of Destination • You hav ave a medical emergencyy du during a shore excursion Tour Operator • A flfligh ightt delay d causes you to miss a connection Cruise Line • Upon on ar arriv arriv rival a at you al yourr dest destina inatio tionn your your lu lugga gg ge is not foundd $200,000 $35,000 00 Optional Upgrade MM / DD / YYYY Primary Traveler Full Name MM / / YYYY Trip Cost $ / YYYY Trip Cost $ / YYYY Trip Cost $ YYYY Trip Cost $ DD Second Traveler Full Name Birth Date 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 excludes excludes trip cancel exclu anc latio lation** n n** $20 $25 $29 $29 $32 2 $36 $67 67 7 $500 $23 $31 $39 $45 $56 $88 Address - $1,0 $1,000 00 $31 $40 $49 $55 $76 $132 City $1 Baggage & Baggage Delay MM $501 $50 - MM / DD Birth Date MM $1,001 - $1,500 $40 $54 $58 $74 $96 $184 $1 $1,5 1 01 01 - $2,00 2,000 0 $ $5 $53 $67 67 7 $7 $7 $76 $100 $133 $235 235 Beneficiary Name Emergency Medical Expenses $2,001 - $2,500 $68 $85 $95 $122 $162 $286 Pro rovid vid des cov covera era erage rage for em emerg erg genc ency n y med medi ed cal tr t eat ea men m t if if a sick sick i k nes ness o ne orr i nju njury u ry occ o ccurs occu oc urs ur rs wh w h ile whi i l tr trave avelin ave li g. lin g $ 01 $2,5 01 - $ $3,00 3,00 00 00 $81 $ $10 $100 $112 $1 12 $144 $144 $192 $338 $3,001 - $3,500 $101 $116 $134 $167 $264 $389 Emergency Medical Evacuation $3,5 501 01 - $4 $4 4,00 000 0 $ 29 $129 $145 5 $ 65 $1 $165 $188 188 8 $3 $30 $300 $ 30 $44 $440 440 0 Pr vid Pro vides cov covera er ge era g fo for or em eme merg ergenc er ncyy evacuat nc vac vac cuat uattion ua on n, iff n nece ece c ssa ssary, ry to o the he ne eare arest s qua st qualif lilified ied me m dic dic cal al fac a ilililty, t al ty a so inc nclud nc u es ud e rep ep patr atriat iat a ion on.. $4,001 - $4,500 $143 $164 $193 $236 $334 $491 $4 $4,5 4 501 01 - $ $5,00 5,, 0 5,00 5,0 $159 15 159 59 59 $181 $181 $1 $214 214 2 21 1 14 $ $26 $264 $37 $370 $37 $54 $541 $54 541 4 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 will willl appl apply per per pplan; plan lan a s sold perr hhouse ousehold ouse hhold ho o . Ra are subj Rates u ec ect to chang chang ha ge. / DD / Transportation Pak One up One upgra gra g ade e wi wit itth two wo gre g at at ben benefi efiits!! Th The e pak ak inc clud ludes es flilight g ac cci ci ent cid ent c co ov verrage e fo f r eac ach a c trave trave tr ve eler err an and nd rent ntal car damage dam ag prrote tecti te ction. i n Ava A aila able e fo or an a addi d tio dd ddi tional na na al $5 59 per pla an. n. For questions, quotes or to enroll, visit www.travelexinsurance.com or call 1-800-228-9792 Primary Traveler Email (Provide to receive Confirmation of Coverage via email) Premium Calculation Total Base Plan Rate $ (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) * Prov Provided ided by Trav a elex av elex’s ’s desig s nate natedd assist assisttance ance pro provide vider. 2 Zip (Estate designated if left blank) Primary Traveler • • • • DD State Safegu Saf eguard ard ds pers ersona ona n l arti arti t cle cless and exp e ens en es iff bags bag ags a are re los ost, os t, stolen sto len,, d len dama am ged ama ged,, or or dela dela elayed yed fo for 12 hourrs or or more e. ** Receive Rece eceive ve all al other othe her base basee pplan la benefits lan f s inc includi luding ng $500 $500 in trip rip inte interrupption in tio ion on co covveerag r e. / Fourth Traveler Full Name Daytime Phone 1 Return Date YYYY Airline Birth Date Base Plan Rates Per Person Trip Cost Includ Inc ludes lud e s rei es reimbu mburse mbu rsemen rse mentt ffor men or unu n sed d, n non on-ref refund und able bl exp pens enses ses es and d ad addit ddit ditional al cos ostts ts suc such u h a as s acco ac cco co ommo mmodat mmo dation dat ions ion s, s, tra ra ansport nsp sport ortati ation a and d me meals lss if i your your yo ur con connec nnec nectio tion tio n is miss miss issed d by by 3 hour hour ou s o orr more more o ffo or a co c ver v ed ed rea ea ason son. Inc nclud lud lu udess a w u wide ide de ra range ng nge g of o se ervi r ces c b be efor ore and and nd dur during during ng n g ttrrips ips thr hrough oug ugh a 24 24/7 /7 tol /7 o l free ee e nu number. mbe m be er Inc Inc clud u ess a asssist i anc is a e with th med e ica ca al emer me ergen encie cie i s, s los lostt docu umen me ts t or o bag aggage, eve vent n tic ic cket keting ing,, busi usines nes e s serv e ice c s, and ce a mu m ch c mor more. e / DD Third Traveler Full Name Missed Cruise Connection Travel Assistance & Concierge* / MM Traveler Details Birth Date • Flight Accident AD&D (per (pe person) • Rental Carr Damag Damage Protection ion (per per pla plan) n) STB 0811 Trip Details (on pg 7 of brochure) Transportation Pak Trip Delay Please print clearly for accurate processing. • You or a family member become illl and a yo y u can can no lon longer g tr t avel • You los l e your ur pa p ssp s ort and need assistance to ret return urn ho hom me me Optional Upgrades Enrollment Form 4 8.00 Enrollment Form Enrollment Options Please print clearly for accurate processing. STB 0811 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 $ (calculate below for all travelers) + $ Primary Traveler + $ Second Traveler Optional Transportation Pakk MM / YYYY 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 free look period. $ ($59) Date 8.00 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. 5