1. finance
2. personal finance
3. insurance

Enrollment Options
Travel Agent
Tra
Conttact your local travel agent.
Internet
Int
Visit us at www.travelexinsurance.com to get a
quotte, learn more or to purchase.
Phone
Ph
Spea
ak with an experienced customer service
representative available at 1-800-228-9792,
M-F
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 m
mail to: Travelex Insurance Services, PO Box
641070, Omaha, NE 68164-7070.
6410
Don’t forget to order foreign currency!
Contact your local travel agent or visit www.travelexinsurance.com.
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)
Signature
(Mandatory for all payment types)
Date
MM
/
DD
/
YYYY
Plan fees are non-refundable after 10 day review period.
Any person who knowingly and with intent to defraud any insurance company
or other person, files an application for insurance or statement of claim containing
any materially false information or conceals for the purpose of misleading,
information concerning any fact material thereto commits a fraudulent insurance
act, which is a crime and subjects such person to criminal and/or civil penalties.
If you reside in: CA, FL, LA, MO, NY, PA, or WA, please call 1-800-819-9004 to obtain
fraud wording specific to your state of residence.
5
Exclusions & Limitations
Meet Your Travel Needs
The following exclusions apply to Trip Cancellation & Trip Interruption, Trip Delay,
Missed Connection, Emergency Accident & Sickness Medical Expense, Emergency
Evacuation & Repatriation of Remains, Accidental Death & Dismemberment, and
Optional Flight Accidental Death & Dismemberment. Loss caused by or resulting from:
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:
Pre-Existing Conditions, as defined in the Definitions section (except Emergency
Evacuation and Repatriation of Remains) unless the insurance is purchased within
thirty (30) days of the initial Covered Trip deposit; Suicide, attempted suicide or
any intentionally self-inflicted injury while sane or insane (in Missouri, sane only)
unless results in the death of a non-traveling immediate Family Member; War,
invasion, acts of foreign enemies, hostilities between nations (whether declared or
not), civil war; Participation in any military maneuver or training exercise; Piloting
or learning to pilot or acting as a member of the crew of any aircraft; Mental or
emotional disorders, unless hospitalized; Participation as a professional in athletics;
Participation in underwater activities (does not include recreational swimming); Being
under the influence of drugs or intoxicants, unless prescribed by a Physician or unless
results in the death of a non-traveling immediate Family Member; Commission or the
attempt to commit a criminal act; Participating in bodily contact sports; skydiving;
hang-gliding; parachuting; mountaineering; any race; bungee cord jumping; and
speed contest (speed contest shall not include any of the regatta races); scuba diving
(unless accompanied by a dive master and not deeper than 50 feet); spelunking or
caving; heliskiing or extreme skiing. Exclusion does not apply to Trip Cancellation.
Bodily contact sports means any sport where the objective is to physically render an
opponent unable to continue with the competition such as boxing and full contact
karate; Dental treatment except as a result of an injury to sound natural teeth limited
to $750; Any non-emergency treatment or surgery, routine physical examinations,
hearing aids, eyeglasses or contact lenses; Pregnancy and childbirth (except for
complications of pregnancy) except if hospitalized; Traveling for the purpose of
securing medical treatment; Services not shown as covered; Directly or indirectly, the
actual, alleged or threatened discharge, dispersal, seepage, migration, escape, release
or exposure to any hazardous biological, chemical, nuclear radioactive material, gas,
matter or contamination; Care or treatment that is not medically necessary; Injury or
Sickness when traveling against the advice of a Physician; Cosmetic surgery
except for: reconstructive surgery incidental to or following surgery for trauma, or
infection or other covered disease of the part of the body reconstructed, or to treat a
congenital malformation of a child.
Some exclusions may not be valid or wording may differ in your state of
residence. For full details, please consult the Certificate of Insurance at
www.travelexinsurance.com or call 1-800-228-9792.
Please refer to the Certificate of Insurance for Baggage/Baggage Delay and Optional
Collision Damage Waiver exclusions.
DEFINITIONS:
Pre-Existing Condition means any injury, sickness or condition of You, or Your
Traveling Companion for which within the sixty (60) day period prior to the Effective
Date of Trip Cancellation coverage under the Policy (a) first manifested itself or
exhibited symptoms which would have caused one to seek diagnosis, care or
treatment; (b) required taking prescribed drugs or medicine, unless the condition
for which the prescribed drug or medicine is taken remains controlled without any
change in the required prescription; or (c) required medical treatment or treatment
was recommended by a Physician.
Underwritten by Nationwide Mutual Insurance Company and affiliated companies.
This product may not be available to residents of all states. This brochure is a
partial description of benefits. Certain terms, conditions, exclusions and limitations
apply. Please visit our website at www.travelexinsurance.com and refer to the
Certificate of Insurance for full details. © 2008 Travelex Insurance Services, Inc.
6
Travel Max
Maximum Travel Protection with
Cancel for Any Reason Option
Primary Coverage
Receive reimbursement for your eligible losses from
Travelex first, 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, including
$1,000 in trip interruption coverage!
Identity Theft Services
Travel securely knowing that Travelex will be there with
time-saving ID theft services should the unthinkable occur.
30 Day Pre-Existing Waiver
Purchase the plan within 30 days of initial trip deposit and
pre-existing medical conditions are eligible for coverage.
Satisfaction Guarantee
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.
"Click" here to purchase online
Please reference the following when enrolling:
LOCATION NUMBER
AGENT CODE
47-0111
COMPANY NAME
TravelersMed.com
0109
7
MTM 1008
MTM 1008
Benefit Highlights
Benefits & Rates
Trip Cancellation & Interruption
Base Plan Benefits
Protec
ects
ts travel inves
vestme
m nts if a trip is cancelled or
interr
int
errupt
upted
ed. Recover pre
prepaid trip costs for the following
covered
d reas
r easons
on :
• Sickness, Acc
A ide
identa
ntall Inju
Injury or Death
• Weather
• Trip Delay of 50% or more
• Strike
• Bankruptcy/Default
• Terrorist Incident
• Residence/Destination Uninhabitable
• Quarantine
• Traffic Accident en Route
• Hijacking
• Employm
oym
y ent
ym
en Termination/Transfer
• Jury Duty
• Felonio
F
ouss AAss
sssaul
a t
au
• Subp
bpoen
oenna
• Dea
Deatth/
h/Hoosp
h/H
ospita
spitaliz
lizati
aatition of Des
Destination Host
• Mili
ilitar
taryy Dut
tar
Duuty
ty
• Busi
Busi
usines
nesss Re
Reas
easons
ea
• Burglary
Optional Upgrades
100% of trip cost ($50,000 limit)
Trip Interruptiion
150% of trip cost ($75,000 limit)
Trip Delay/M
y/Missed
ed Connection
Bag
aggag
gage/B
e/Bagg
ag age Delay
$25,00
$25
,000
0
Common Ca
Commo
arr
rrri
rier AD
AD
AD&D
$50
50,00
,00
0 0
Missed Connection
Tra
ranspo
sp rtatio
i n Pak
C cel for Anyy Reaso
Can
son Pak
k
80 of trip
80%
ip co
cost
Coverage Per Plan
• Flight Accident AD&D
• Collision Damage
g Waiver
• Roads
Roadside Assi
ssistan
stance
e
$200,0
$
0,000
00
$3 ,00
$35
00
Includ
Inc
luded
ed
Trip Cost
Saffegu
eguard
ardss persona
ar
ard
ers
rso
ona
nal
al arti
arti
rticle
cles
cle
s and
and exp
expens
ens
n ess if
if bag
bagss are
e llo
los
o t,
t,
stolen
sto
olen,
len
en, dama
amaged
am
ged, o
ged
ged,
ge
orr d
dela
elayed
ela
l yed
d ffo
or 1
12
2 hour
ourss or
or more
ore. Incl
ore.
nclude
nc
ude
d s
co era
cov
erage
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e for
f
pe
perso
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na bu
nal
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siness
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and a renta
renta
ntall
allowa
all
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nce fo
forr lost
lostt, stol
tolen
en or
or dam
damage
a d spor
age
portin
t g equi
tin
qu p
pme
m nt.
Emergency Medical Expenses
Provid
Pro
vides
vid
vi
es cov
covera
co
era
erage
age for
fo emerg
emerg
ergenc
enc
ency
ncy medi
medi
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ca treat
cal
treat
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sick
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or inju
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njury
ryy occ
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rss wh
w ile tr
trave
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ave
ling.
n g.
g . Inc
In ludes
lud
udes
es
p tec
pr
pro
te tio
t n for
for tra
av
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g pets.
petts.
s.
Emergency Medical Evacuation
Pro
rovvid
ro
id
des
e cov
c era
e ge
ge for
or em
e
emerg
merg
ergenc
enc
e
ncy evac
evac
vacuat
uation
uat
io
o , if
if nece
necessa
ssary,
ry, to
ah
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it
off choi
cho
hoice,
hoi
ce,
e,, al
als
so inc
n lud
nc
ludes
e rep
patr
atriattion
ion.
Accidental Death & Dismemberment
Provid
Pro
r vid
ides cov
id
c era
e ge
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fo
o loss
loss
s of liffe, lim
im
mbs
s or
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m an
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jury whi
while
hile
l tra
ra
avel
veling
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ing
ing
go
or on
n a com
c mon
mo
o carrier.
Travel Assistance & Concierge
•
•
•
•
Ages
0-34
Ages
35-50
Ages
51-60
Ages
61-70
Ages
71-79
Ages
80+
$
$0 exclu
cludes
ddes trip cancel
cancel
an latio
t n
$24
$30
$35
$35
$51
$65
6
$134
$1
$501
$501
$1,001
$1
$1,5
$1,501
1 501
$2,001
$2,501
$2,5
01
$500
$1,0
$
,000
$1,500
$
$2,00
2,000
2,00
0
$2,500
$3,00
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0
$35
$
$62
$89
$11
$111
$142
$167
7
$41
$72
72
$103
$140
1
140
$176
$2
$207
$43
$
$76
$107
$1
$147
$183
$220
$61
$104
104
$146
$186
$230
$268
$78
$139
13
39
$198
$259
$331
$
$391
$210
$338
338
8
$502
$666
666
$833
$
$99
$998
$3,001 - $3,500
$200
$259
$266
$310
$460
$1,167
$3
$3,5
$
3 501
$4,001
$4,501
$4,5
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$5,001
$5,501
$5,5
5,501
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$6,001
$6 501
$6,5
$6,501
1
$7,001
$ 001
$8,0
$8
01
$9,001
$222
$248
$272
272
72
2
$321
$34
$345
45
$377
$40
$404
404
$472
$539
$615
$296
$333
$377
$3
$37
$
37
3
$442
$475
475
$530
$56
$5
$565
$635
$737
$826
$301
$338
$387
8
$449
$48
$489
89
$544
$ 9
$5
$589
$656
$757
7
$851
$355 $537 $1,3
, 34
4
$393 $625 $1,500
$4
$431
$70
$702
$
7
$1,6
1,, 60
1,6
$520 $755 $1,762
$56
$564
564 $799
799
9 $1
$1 06
$1,806
$1,8
$1,
$623 $894 $2,032
$65
$656
$6
6 6 $948
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948
4
$2,1
2 8
85
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$748 $1,071 $2,479
$848 $
$84
$8
$1
$1,2
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1,206 $2,8
$ 815
$2
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$954 $1,342 $3,184
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$
$4,00
4,000
0
$4,500
$5,00
$5,00
5,000
5,0
0
$5,500
$
$6,00
6, 0
6,00
$6,500
$7,00
, 00
,00
$8,000
$9,00
$9,00
9 000
9,0
$10,000
/
DD
Return Date
YYYY
For rrates on trip costs above
vee $10,0
$10,
0 000
00 plea
please
ease call
a 1-80
al
-8000-22
0-2 8-97
-97
97792
9792.
9
92.
Maximu
ximu
m m trip
trip lengt
gthh aallowe
allowe
lowedd 1880 da
days.
ys For trip
ipps 31-1800 day
ayys in le
ays
len
e gth add $55 per daay.
ayy
An $8 processi
essi
ss ngg ffee
ee willl app
appl
ppply per pplan.
pp
Raates
es aare
re subj
subject
ec too chang
hange.
hange.
e.
DD
/
YYYY
Airline
Cruise Line
Cancel for Any Reason Pak
Pro
Prot
otectiio
on
n again
ga st the
e unexp
pecte
ected,
d, w
whate
atever
ver
er it
i mayy be!
e! P
Purch
urchas
ase
this pak
th
ak an
and
nd
d eve
e ryon
r yone on the
th pla
plan
n receiv
eivess tthe
hese
ese two
tw benefitts:
• Cancel
Ca cel a trip prior to
o 2 days of the
he sched
duled
l d dep
de artu
rture
rtu
re date
t
and
nd re
eco
over up to 80%
8
80
of trip cost.
• Plus
Plus Cance
Cance
el fo
for T
Trip Delay
Delay Reas
Reasons - This adde
dde
ed benefi
benefit
fit allows
ws
canc
ancella
ellatio
tion due to 30% or more
more o
of a trip bei
being miss
missed from a
covered
co
d de
delay
y and
and recov
cover up to 100%
00% of tr
trip co
cost.
Must be purc
purchase
has d within
hin 21 days
days of the initial
ial
al trip
trip dep
posit
o t.
Availabl
ble
e fo
forr additi
ditional 50%
5
of total
tota
t lb
base plan
plan rate
e.
Traveler Details
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
Birth Date
MM
/
DD
/
Address
City
State
Zip
Daytime Phone
Beneficiary Name
(Estate designated if left blank)
Primary Traveler Email
(Provide to receive Confirmation of Coverage via email)
Transportation Pak
One
ne upgr
upgrad
rad
ade
d with
witt th
three
e great
ea
a ben
nefit
fits!
s! Inclu
cllud
c
des flig
fli ht accident
a
co rage
cov
cove
rag
g , ro
oadsi
ds de
e assis
sistance, and
sis
d a co
colllisi
isi
sion d
sion
damag
ama
amag
m e waiver for
r al ve
rent
ehic
h les.
e Pur
Purchas
Pu
ch e this
chas
ch
thi pak
k and
d cove
erage
age
g lim
limits
its
ts are
re shar
h ed
amon
m g all tr
t avel
ellers
rs enrolled
enro
n lled
e on tthe
e plan.
Avai
Ava
a labl
ab
abl
b e fo
for a
addit
d onal
diti
ona
na
nal
al $
$49 per
pe pla
an.
For questions,
qu
quotes or to enroll,
www.travelexinsurance.com
visit w
or call 1-800-228-9792
Premium Calculation
Total Base Plan Rate
$
(calculate below for all travelers)
+ $
Primary Traveler
+ $
Second Traveler
Trips 31-180 days in length
(include arrival and departure days)
# travelers
Optional Cancel for Any Reason Pak
Optional Transportation Pakk
3
=
$
x $5 =
$
+ $
Third Traveler
x
Fourth Traveler
# days
(Base Plan + Extra Days x 50%)
Base Plan Total
Extra Days Total
$
$
($49)
$
$
Processing Fee
(and authorized as payment)
2
/
Tour Operator
Total Amount Due
1
MM
Fourth Traveler Full Name
(use full cost per person)
-
/
MM
Country of Destination
Base Plan Rates Per Person
Baggage & Baggage Delay
Inc
IIn
ncludes
lud
udes a wide
wide
de ra
r nge of sservi
rv ces
c
ce
befor
be
efo
for
o e and
and durring
ing tr
in
t ips
trips
ps
p
s
thr
hroug
o h a 2
oug
24/7
7 tol
to l free
ee nu
n mbe
b r.. Inc
nc
cllud
u es
ud
es Nur
Nurse
e Ass
As
Assist
s ist
sstt and
a
and
hel
ellp w
with
it m
ith
medic
d al eme
em
m rge
rg nci
nc es,
nc
e lo
l st
s doc
do
o ume
um
ments or ba
bagga
g ge,
gg
gga
ge
eve
vent
ntt ttic
cketting
n , busi
ng
busi
usin
nesss serv
nes
servvice
ices,
ic
s and
s,
an mu
m ch
c mor
m e.
IInc
nclud
l ed
d
Coverage Per Person
Inc ludes
In
es rei
reimbu
mbursemen
e t for unu
nused
ed,, n onon-refundable
exp
pen
ens
nses
es and
an addit
addition
ional
al costs
ts such
h as acco
ccom
mmodat
dation
io s,
transp
nsport
ortati
r ation,
on
n and meal
eals
s to
to rre-j
e-join
n a cru
cruise
ise if a fli
flight
ght delay
delay
c ses yo
cau
your
ur con
co nection to b
be
e miss
missed
ed by
y3h
hour
ourss or m
more
re.
Departure Date
$1,000,000
24 Ho
Ho
Hou
ourr AD&D
ou
D&
&
Optional Upgrades
(on pg 7 of brochure)
$100,000
Eme
Eme
merg
rge
rg
gency Medical Eva
g
va
acua
cuatio
tion/R
tio
n/ ep
n/R
e triation
epa
Provvides
es rei
reimbu
mburse
emen
ent
nt for unu
un sed, prepaid, non-refundable
exp
penses
ens an
and ad
addit
d ion
dit
ional
al cos
costs
ts suc
such
h as accommodations,
tra
transp
ransp
sportati
atio
on, and meal
ealss if
if a tr
trip
ip
p iiss del
ela
ayed 5 ho
ay
aye
hours or more
for a cov
cov
overe
ered
d reas
reason
on.
Location Number / Agent Code
$2,500 / $600
Emerge
Eme
rgency
ncy Accident
Ac ent & Sickness Medical Expense
MTM 1008
Trip Details
$1,000
Travel
Tra
vel
el Assistance & Concierge
Trip Delay
Please print
Pl
i t clearly
l l for
f accurate
t processing.
i
Coverage Per Person
Trip Cancelllat
a on
ati
n
Enrollment Form
4
8.00
Enrollment Form
Enrollment Options
Please print clearly for accurate processing.
MTM 1008
Travel Agent
Tra
Trip Details
Cont
Contact your local travel agent.
Location Number / Agent Code
(on pg 7 of brochure)
Departure Date
/
MM
/
DD
Return Date
YYYY
MM
/
DD
/
Internet
Inte
YYYY
Visit us at www.travelexinsurance.com to get a
quote
quote, learn more or to purchase.
Country of Destination
Tour Operator
Cruise Line
Phone
Pho
Airline
Spea with an experienced customer service
Speak
repre
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.
Traveler Details
Primary Traveler Full Name
Birth Date
MM
/
/
YYYY
Trip Cost $
/
YYYY
Trip Cost $
/
YYYY
Trip Cost $
YYYY
Trip Cost $
DD
Fax or Mail
Second Traveler Full Name
Birth Date
MM
/
DD
Fax b
both sides of enrollment form to 1-800-867-9531
or m
mail to: Travelex Insurance Services, PO Box
6410
641070, Omaha, NE 68164-7070.
Third Traveler Full Name
Birth Date
MM
/
DD
Don’t forget to order foreign currency!
Contact your local travel agent or visit www.travelexinsurance.com.
Fourth Traveler Full Name
Birth Date
MM
/
DD
/
Payment Details
Address
City
State
Check or Money Order (payable to Travelex Insurance Services)
Zip
MasterCard®
Discover®
American Express®
Daytime Phone
Visa®
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
Trips 31-180 days in length
(include arrival and departure days)
+ $
Third Traveler
x
# travelers
Optional Cancel for Any Reason Pak
Optional Transportation Pak
=
Fourth Traveler
# days
x $5 =
(Base Plan + Extra Days x 50%)
Signature
$
Base Plan Total
$
Extra Days Total
$
$
($49)
$
$
Processing Fee
Total Amount Due
(and authorized as payment)
MM / YYYY
4
8.00
(Mandatory for all payment types)
Date
MM
/
DD
/
YYYY
Plan fees are non-refundable after 10 day review period.
Any person who knowingly and with intent to defraud any insurance company
or other person, files an application for insurance or statement of claim containing
any materially false information or conceals for the purpose of misleading,
information concerning any fact material thereto commits a fraudulent insurance
act, which is a crime and subjects such person to criminal and/or civil penalties.
If you reside in: CA, FL, LA, MO, NY, PA, or WA, please call 1-800-819-9004 to obtain
fraud wording specific to your state of residence.
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