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*
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Documeented
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assspor
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V sa The
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Safe
Sa
feguar
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ds perso
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Emergency Medical Expenses
Prov
Pr
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emer
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genc
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en
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nclu
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dess
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prot
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s.
Emergency Medical Evacuation
Prrov
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ge fo
forr em
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on,, if nec
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sary
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th
the
he ne
near
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ar
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f ciility, allso
s inc
clu
l de
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atr
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tion
on
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Accidental Death & Dismemberment
Prov
Pr
rovid
ides
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es cov
over
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age
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loss
ss of lilife
fe,, liim
fe
mb
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o sig
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m a cove
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acci
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dent
de
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ytim
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duri
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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
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ing
in
g tr
t ips
ip
ps
thro
th
r ug
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2 /7
/ tol
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e num
mbe
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nclu
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A si
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initiial trip depos
osit.
os
** Pro
Provid
vided
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desi
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gna
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ance
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provid
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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
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Carr Dama
D m ge Protec
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tion
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(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
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its, each auto
toma
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alllly
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ase
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he pak
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accide
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for ea
ach
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and
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da
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Ages
0-34
Ages
35-59
Ages
60-69
Ages
70-79
Ages
80+
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on***
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6
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$120
$12
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$15
7
$199
$236
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6
$68
$ 7
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$163
$206
$20
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$ 4
$29
$89
$15
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155
$219
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$32
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$52
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$62
$702
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$ 955
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6,000
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000
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*** Rece
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inte
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• Maxi
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180 ddaays. Foor trips
rip
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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
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f e will
will appply pe
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Ratess are
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to chan
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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
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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
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Prov
Pr
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tran
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ne
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on and ken
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e if a tr
trip is
dela
de
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d 5 ho
hou
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on.
Enrollment Form
Coverage Per Person†
Trip Delayy/M
/ isse
ed Cruise Connection
Trip Delay
In
n cl
c ud
des rei
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ment
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ason
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Maximum Luxuries
Birth Date
MM
/
DD
/
Address
Upgrad
City
e
Cancel for Any Reason Pak
P ot
Pr
otec
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tion
on aga
gain
inst
stt the une
nexp
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xp
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upgr
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and
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ever
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the
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plan
an rec
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eive
vess
thes
th
ese
e tw
two
o be
bene
nefi
fits
ts:
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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
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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