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. 26232192A In today’s travel environment it’s important to protect you and your trip investment. Meet your luxury travel needs with our maximum coverage plan and find the peace of mind your trip deserves with these valuable plan highlights: 6 Travel Max Deluxe 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. Cancel for Any Reason Upgrade Purchase this pak for protection against the unexpected. Cancel your trip for absolutely any reason, plus cancel for trip delay reasons! 30 Day Pre-Existing Waiver Purchase the plan within 30 days of initial trip deposit and pre-existing medical conditions are eligible for coverage. Post Departure Protection Select the $0 trip cost level if you don’t need cancellation coverage. Receive all other base plan benefits, plus $1,000 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 STM 0811 STM 0811 Benefit Highlights Benefits & Rates Trip Cancellation & Interruption Base Plan Benefits Protec ct travel invesstm tmen e ts and recover non-refundable, prep pr epai aid d tr trip ip costs if a tr trip is cancelled or interrupted due to a cov ver ered ed rea eason. Ref efer to the Description of Coverage for details. • Sickness, Injury or Death • Weather • Trip Delay of 50% or more • Strike • Financial Insolvency • Quarantine • Residence/Destination Uninhabitable • Hijacking • Trafficc Ac A ci c dent en Route • Jury Duty • In Invo volunttary ary Em Empl ploy oyment oy y Termination/Transfer • Subpoena na • Mi M lilita t ryy Dut ta uty fo forr N Naatu tura rall Di ra Disa sast ster e • Teerr rroor oris ori ist Ac ist Actt • Deat Deeat a h/ h/H Hosp Ho spiital ital aliz izat atio at ionn of Destitna nation Hostt • Mandatory Evaccuati uaatit on • Coomm mmoon Car arri rier er Canc anncellaat atioons atio ns/D /Del elay ayys • Business Bu Reasons* • Do Documeented ntted Pas assspor sport/ t/Vi V sa The Vi heft Safe Sa feguar fegu fe gu uar ards ards ds perso errso ona nal al ar arti ticl ti cles cl les and nd exp xpen ense en sess iff bag se agss arre lo lost st,, st stol st o en ol en,, da dama m ged, ma ge ed, d or de dela la aye yed d fo forr 12 1 hou o rs or mo more re.. In re Incl clud cl udes ud es cove co v ra ve age g for per erso s na so nall bu busi s ne si ness s pro ss ope p rt r y an nd a re en nttal alllo allo lowa wanc wa n e fo nc forr lo l st st,, st stol ollen olen e or da ama mage ged sp ge spor orti or t ng ti g equ quip ip pme ment ntt. Emergency Medical Expenses Prov Pr ovid ov ides id es cov over erag er age ag e fo forr em emer errge genc nc ncy cy m me edi d ca call tr trea ea atm tmen e t if en if a si sick ckne ck ness ne ss or in inju j ry occ ju ccur u s wh ur whililile e trav tr avvel tr elin i n g. Inc ing. nclu lude lu dess de prot pr o tec ot ec c ti t on o for o r tra rave velilil ng ve g pet ets. s. Emergency Medical Evacuation Prrov o ides id dess cov over ver erag ag age ge fo forr em emer erge g nc ge ncyy ev e acuation on,, if nec eces essa sary ry,, to th the he ne near ares ar esst qu est ualif aliiffied al ie ed me m dica c l fa f ciility, allso s inc clu l de es re epa atr tria iati tion on o n. Accidental Death & Dismemberment Prov Pr rovid ides id es cov over erag age ag e fo forr lo loss ss of lilife fe,, liim fe mb bs or o sig i ht h fro rom m a cove vve ere red d acci ac cide dent de ntal al inj njjur ury anyt ytim tim me du duri ring ri n yourr tr trav avvell or as a a passe enger on a com on ommo mon carr ca arrrie ier. Travel Assistance & Concierge** In ncl clud u es a wid de ra range e off ser ervi vice cess be ce efo fore or and d dur urin ing in g tr t ips ip ps thro th r ug ro gh a 24 2 /7 / tol o l fr free free e num mbe b r. Inclu nclu nc l de des Nu N rsse As A si s st an nd d h lp he p wit ith h me m di d ca c l em e e errge g ncie es, s los st do ocu cume entss orr baggage, evven nt ti tick cket ck ettin ng, bus u in nes e s se s rvvic i es es,, an and d mu m ch h mor ore. e * Req equi uire ress pllan pur urch c as ch a e wi with thhin i 30 da d ys of in initiial trip depos osit. os ** Pro Provid vided e by Traavel ed e ex’ el x s desi desi esigna es gnated gna ted asssis i tan ance an ce pro provid v er. vid 1 100% of trip cost ($50,000 limit) Trip Interruptio ion on 150% of trip cost ($75,000 limit) Location Number / Agent Code (on pg 7 of brochure) Departure Date $ 5,00 $2 000 0 Comm mon on Car arri r er AD&D D& $50 $5 0,00 0,00 0, 000 I clud In ded d Maximum Luxuries Transportation Pak NO COST! $200 0,0 ,000 00 $50 $5 0,00 000 0 • Flight Accident AD D&D (pe perr p pers erson on) • Rental Ca Carr Dama D m ge Protec ctio tion n (pe (p r pllan) Cancel for Any Rea easo son n Pak Transportation Pak No Cost! O e pa On p k with two w gre eat a ben nef efit its, each auto toma m ti tica alllly y in ncluded ed d in yo yourr bas ase e pllan a rat ate! The he pak a inc ak ncllu ludes fl lude flig ight ht accide ent cov o er era age fo for ea ach h travele er an and d rental car da amage pro rote ectio on. Ages 0-34 Ages 35-59 Ages 60-69 Ages 70-79 Ages 80+ $0 excclud udess tri tripp canc canc a ell ellati ation* on*** on* *** $36 $ 6 $4 $45 $ $63 $83 $ 5 $21 $500 $ 000 $1 $1, $1,500 $2,0 2 000 0 $2,500 $3,0 3 00 0 $38 $ $6 $67 $96 $120 $12 $158 $185 $18 5 $48 $80 $80 $115 $157 $15 7 $199 $236 $23 6 $68 $ 7 $1 $11 $163 $206 $20 6 $253 $ 4 $29 $89 $15 $155 155 $219 $285 $28 5 $362 $42 $ 27 $333 $ 0 $51 $547 $724 $724 $72 $905 $1 $1, 1 083 8 83 $3,001 - $3,500 $221 $289 $340 $502 $1,265 $3,501 $3,501 $4,001 $4 501 $4, 50 0 $5,001 $5 $5, 5 501 01 $6,001 $6,,501 501 1 $7,001 $8 001 $8, $8 0 00 $9,001 $245 $245 $273 $299 $29 9 $352 $37 3 8 37 $412 $441 $44 41 $515 $58 5 7 58 $669 $32 $327 $367 $41 418 4 $486 $526 $52 6 $585 $628 $6 $628 $62 $702 $ 2 $81 $911 $38 88 $429 $47 $ 470 70 $567 $6 4 $61 $678 $71 $713 7 3 $813 $921 $92 $9 1 $1,035 $585 $585 $680 $763 $76 $820 $86 $8 $86 8 8 $971 $1, $1 $ 1 029 29 $1,162 $1, $1 1 307 $1,454 $1 446 $1,446 46 6 $1,625 $1,798 $1, $1 798 9 $1,908 $ 955 $1, 55 5 $2,200 $ 365 $2, 6 $2,682 $ 045 $3, 045 5 $3,444 $1 $501 $5 01 1 $1,001 $1 501 $1, 50 0 $2,001 $2,501 $2, 5 501 - $4,000 4 000 $4,500 $5,0 5 000 5,000 $5,500 $6,0 6,000 00 $6,500 $7,0 7,0 7,000 00 00 0 $8,000 $9,0 000 $10,000 *** Rece ceeiv i e alll other baase s plaan be b ne nefi efifitss inc n ludiingg $1,0000 inn triripp in inte terr rrup u titonn cov over eerrag age. e e. • For o rates onn tri tripp cost costs abov oove $10,000 0 pleasse call al 11-800 -800 00-22 -22 -2 22228-9 8 9792 7 . • Maxi ximu xi mum m um tr trip ip length gth t al th allow lowed owe 180 180 ddaays. Foor trips rip i s 31-1 31-1 1-180 80 day 80 daayss in in lleng ength eng thh ad add $88 pe per day. per • An $8 proc process esssingg fe f e will will appply pe perr plan; lan an; plan anss sold an ol peer hous ouseho ehold eho ld. ld • Rate Ratess are re sub suu jec jectt to to chan chan a ge gge. e 2 / DD / YYYY Airline Primary Traveler Full Name Birth Date 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 Birth Date MM / DD Fourth Traveler Full Name Base Plan Rates Per Person Use full cost per person, include all non-refundable, prepaid travel costs. MM Traveler Details Coverage is up to the limits shown per person. Limitations and exclusions apply. Trip Cost Return Date YYYY Cruise Line UPGRADE 75% 75 % of trip p co cost st 10 00% % of tr trip ip cos ostt • Cancel for Any ny Re Reason • Canc C n el forr Tr Trip ip Delay Rea ason so s / DD Tour Operator $1 million 24 Hou our AD A &D & / MM Country of Destination $100,000 Tra Tr avel Assistance & Concierge*** avel † Trip Details $2,500 / $600 Em mer erge g ncy Me ge M dical Ev vac acua uati ua tion ti on/R on / ep /R e atriation STM 0811 TAHC5001GES Please print clearly for accurate processing. $1,000 Emer Em erge genc ncy y Ac Accident nt & Sickness Medical Expense Missed Cruise Connection Baggage & Baggage Delay Trip Cancelllatio ati n Ba agg ggag age/Ba Bagg g age Delay Prov Pr o id ov i es rei eimb m urseme en ntt for ad a diti tio onall cos onal on osts t such as acco ac com mmodat mmod mm atio ions ns, tr tran a spo ortati tion on,, me m alls, s inter erne n t us ne u age fees es, airl aiirl rliine ine cl club ub adm dmisssion on and ken enn nel co cove vera r ge e if a tr trip is dela de laye yed d 5 ho hou urss or mor o e for a cove vere ed reason on. Enrollment Form Coverage Per Person† Trip Delayy/M / isse ed Cruise Connection Trip Delay In n cl c ud des rei eimb mburse s me ment nt for unu u se sed, d, n on on-rref efun unda dabl be expe ens nses es and d additiona al co cost stss su s ch h as ac acco comm co mmod odat atio ions ns,, tran tr ansp an sp porta orta or t ti tion on and mea eals ls if yo your ur con onne nect ne ctio ct ion io n is mis isse sed d by 3 ho hour urss orr morre fo ur or a co cove vere ve red re d re eas ason on. Maximum Luxuries Birth Date MM / DD / Address Upgrad City e Cancel for Any Reason Pak P ot Pr otec ec cti tion on aga gain inst stt the une nexp xpec xp e te ec ted, d wha hate teve verr it may be e!! Purc Pu rcha hase se e thi hiss up upgr grad ade e an and d ev ever eryo yone ne on th the e pl plan an rec ecei eive vess thes th ese e tw two o be bene nefi fits ts: • Cancel a tri rip p 2 or o morre da days y beffor o e th he sc che h du ule led d de depa pa art r urre date da te e and recov ecov verr up to 75 5% % off trrip p cos ost. t. t. • Pl P uss Can ance cell fo f r Tr Trip p Del e ay ay Rea e so sons ns - Thi ns h s ad adde d d be b nefit alllo a ows s can nce celllat a io on du d e to 30% 0% or mo mo of a tr more t ip p being g m ss mi s ed d fro om a co cove ered de ela ay an nd re r co cove ve up to 10 ver 100% 0 of 0% triip co c st s. Mu ustt be se sele ect cted e at tth ed he time m off in init itiall pllan n pur uc ch hasse, withi itthi hin n 30 30 d ys da s of th the in nitia ittia ial trip ial p dep epos sit dat ate e an and mu m st ins nssurre fu fullll tri rip p co cost cost st.. Avai aiila aila abl b e for an a addit ittio i nal 50% of total base plan rate. For questions, quotes or to enroll, visit www.travelexinsurance.com or call 1-800-228-9792 3 State Zip Daytime Phone Beneficiary Name (Estate designated if left blank) Primary Traveler Email (Provide to receive Confirmation of Coverage via email) Premium Calculation Total Base Plan Rate $ (calculate below for all travelers) + $ Primary Traveler + $ Second Traveler + $ Third Traveler Trips 31-180 days in length (include arrival and departure days) x $8 = x # travelers Optional Cancel for Any Reason Pakk = Fourth Traveler # days over 30 (Base Plan + Extra Days x 50%) $ Base Plan Total $ Extra Days Total $ $ Processing Fee Total Amount Due $ (and authorized as payment) 4 8.00 Enrollment Form Enrollment Options Please print clearly for accurate processing. STM 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 / YYYY Internet Country of Destination Visit us at www.travelexinsurance.com to get a quote, learn more or to purchase. 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 Visa® Daytime Phone MasterCard® Discover® American Express® Credit Card Number ___ ___ ___ ___ /___ ___ ___ ___ /___ ___ ___ ___ /___ ___ ___ ___ Beneficiary Name (Estate designated if left blank) Credit Card Expiration Date MM / YYYY 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 $ + $ Primary Traveler + $ Second Traveler + $ Third Traveler Trips 31-180 days in length (include arrival and departure days) = Fourth Traveler x $8 x # travelers Optional Cancel for Any Reason Pakk # days over 30 (Base Plan + Extra Days x 50%) $ Base Plan Total = $ Total Amount Due If you wish to obtain a fraud statement specific to your state of residence, please call 1-800-819-9004. Extra Days Total Signature $ $ Processing Fee (and authorized as payment) 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) (Mandatory for all payment types) 8.00 Date MM / DD / YYYY Plan fees are non-refundable after 10 day free look period. $ 4 5
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