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.
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)
Signature
(Mandatory for all payment types)
Date
MM
/
DD
/
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.
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 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; 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.
Payment Details
®
Exclusions & Limitations
YYYY
Plan fees are non-refundable after 10 day free look period.
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
an AEGON 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.
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 description of benefits. Your individual policy
or group policy will govern the final interpretation of any provision or
claim. If you are a resident of one of the following states: IL, IN, KS, LA, OR,
OH, VT, WA, and WY, your coverage is written on an Individual Policy. Please
call 1-800-228-9792 or visit www.travelexinsurance.com/SBPlans.aspx to
obtain your Individual Policy or your Certificate of Insurance for all other states.
© 2011 Travelex Insurance Services, Inc. 24205116
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.
Travel Basic
Essential Travel Protection
M ad e E a s y
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, 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.
Open to Page 3 for More Reasons to
Protect You and Your Trip Investment!
Please utilize the location number
and agent code below when
getting a quote or enrolling.
LOCATION NUMBER
AGENT CODE
22-0176
COMPANY NAME
Hamilton Meetings
7
STB 0811
STB 0811
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
upted.
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)
•
•
•
•
•
•
•
•
Trip Dela
ay/M
y/Missed
e Cruise Connection
Sickness, Injury or Death
Financial Insolvency
Residence Uninhabitable
Trafficc Ac
A cident en Route
In olunntaary
Inv
ry Emp
Emplo
loy
o ment Termination/Transfer
Mili
M
iliitar
taryy Duty
u foor Natu
at ral
ra Di
Disas
saster
ter
Dea
De
eath/
t /H
Hospitali
Hospit
alizat
lization
on of
of Desti
Destinat
nation
ion Host
st
Comm
mmon
on Ca
Carrie
rierr Canc
ancell
elllati
ations
ons/De
ons
/Delay
/De
layss
lay
•
•
•
•
•
•
•
Weather
Strike
Quarantine
Hijacking
Jury
ury Duuty
Subpoen
b en
e a
Documentedd
Passport/Visa Thef
eftt
Reasons to Buy
Coverage Per Person
$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 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!
Pro
ovid
des rei
reimbu
mburse
rsem
ment for add
ment
additiiona
onall costs
s such as
acc
accomm
comm
mmoda
odatio
oda
tions,
tio
n transpo
ns,
portation, and
n mea
meals
l iff a tri
trip is
delaye
del
yed
d 5 ho
hours
urs or mo
more for a cov
vere
red
d reason
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
Return Date
YYYY
MM
/
DD
/
YYYY
Airline
Traveler Details
Primary Traveler Full Name
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
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 Cruise Connection
Birth Date
Base Plan Rates Per Person
Trip Cost
IInc lud
udes
es rei
reimbu
m rse
e ment
men
en t forr unu
unused
s ed,, nonon-ref
re undabl
ref
und
dab
able
e
exp
ex
pens
e ses and
d ad
addit
dition
dit
io al cos
ion
co ts suc
such as acco
commo
mmodat
dation
ions,
s,
tra
r nsp
port
ortati
atio
ati
on a
on
and
nd m
me
eals
al iff yo
your
u con
c nnec
nectio
ne
nec
tion
tio
n iiss m
miss
issed
iss
ssed
ed by
by
3 hour
ourss or mo
ore
re fo
f r a co
cover
vver
ered
d rea
reason
sson
on.
Ages
0-34
Ages
35-50
Ages
51-59
Ages
60-69
Ages
70-79
Ages
80+
$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
(use full cost per person)
$0
0 excludes
excludes trip cancel
exclu
anc latio
lation**
n
n**
$1
Baggage & Baggage Delay
$501
$50
Sa egu
Saf
eguard
ar s pers
ard
pers
e ona
n l arti
rtticle
cless a
and
nd
d exp
expens
e es iff bag
ens
ba
ags
s are
are los
lost,
ost,
stolen
sto
len
le
en, dama
dama
am ged
ged,, or
or dela
e ye
yed
d fo
forr 1
12
2 hour
ours
s or more
e.
-
MM
Birth Date
MM
$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
$2,001 - $2,500
$68
$85
$95
$122
$162
$286
Pro
rovid
vid
des cov
covera
era
rage
g for em
ge
emerg
e genc
erg
encyy med
medi
ed cal tr
treat
eatmen
eat
m t if
men
if
a ssick
ick
k nes
n so
orr i nju
njury
ry occ
ry
occurs
oc
u wh
ur
urs
w h ile
whil
il tr
trave
avelin
ave
l g.
lin
$ 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
$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
Travel Assistance & Concierge*
Includ
Includ
ud
des a wide
d ra
r nge
ng
g off se
ervi
rvices
c s be
ces
befor
for
o e and
nd dur
d ing
du
n tr
t ips
thr
h oug
gh a 24
24/7
/7
7 tol
olll ffree
ree
e nu
numb
mbe
b r.
r Inc
clud
udes
ud
e a
ass
ssist
i anc
is
a e with
medica
med
i l emergen
ica
mer
ergen
gencie
cie
es,
s los
ostt docu
umen
ments
ts
s or bag
baggag
ga e, eve
vent
nt
tic
ic
cket
e ing
ing,, busi
busi
siines
ne s serv
er ice
ic s, and mu
m ch mor
more.
e
•
•
•
•
1
For ra
r tes on trip cost
costss ab
above
ovvee $5,0
$55 000
00 pleas
p ea
ease ccall 1-800
eas
-80
80 -228
28-979
9792.
979
2
2.
Maximu
xim
m m tr
trip
ip lengt
g h al
a lowe
ow
w d 30
30 day
da s.
s
An $8 proc
roc
ocessi
oc
es ng fee
essi
fee will
il ap
ap y pe
appl
app
perr pplan.
Rates
Ra
tes
es are subjject
ect
ct ttoo chang
angge.
e
2
DD
/
Zip
(Estate designated if left blank)
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.
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)
+ $
Primary Traveler
* Pro
Prov
ovided
ide byy Travelex
Trav
ravele
e ’s
elex
’s ddes
e natedd assist
esig
assistance
ance pro
provide
vider.
** Rece
**
Rec
ece
cceeive
ive allllll othe
th r bbase plan bene
ben fits
itss inc
n ludi
nc
udi
d ngg $500
50 iinn trip
riiip inte
nte
nterrup
t rupption
io ccov
ovverag
r ge
rage.
/
State
$1,001 - $1,500
Pr vid
Pro
vides
es cov
covera
er ge
era
g for
f em
fo
emerg
merg
ergenc
enc
ncyy evac
nc
evac
vacuat
cua
u ion
uat
on, iff nece
nec
c ssa
ssary
sary,
ry
y
to the
e ne
eare
est
s qua
q lif
qu
lified
ied
ie
ed me
m dic
ca
all fac
a ilililty,
t al
a so inc
nclud
nclud
nc
udes
ud
e
rep
ep
epatr
patr
a iat
a ion
on..
DD
Fourth Traveler Full Name
Daytime Phone
Emergency Medical Expenses
/
+ $
Second Traveler
Optional Transportation Pakk
+ $
Third Traveler
=
$
Base Plan Total
$
($59)
Processing Fee
$
Total Amount Due
$
(and authorized as payment)
3
Fourth Traveler
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