Travel Guard Application Form      

            

               

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Travel Guard Application Form  

APPLICATION FORM

TRAVEL GUARD

Coverage is not in force unless insurer accepts this application.  A certificate validating the coverage will be sent to the applicant.  However, on phone order, this written confirmation is not necessary for the Emergency Travel Services Insurance to be effected.  Benefits may not be payable due to pre-existing conditions.

1. Please provide the following contact information for applicant:
First Name
Last Name
Street Address
Address (cont.)
City
Zip/Postal Code
 Phone
FAX
E-mail
Age
Passport No.
Beneficiary
Relationship
Destination:
Length of Trip (days)
Departure Date: -- mm/dd/yy
Return Date: -- mm/dd/yy

Traveling Family Members:  When purchasing with family, list family members traveling with the applicant: spouse and children under 23 years.  Non related traveling companions and children age 23 or older must fill out separate applications.

Spouse:
First Name
Last Name
Age
ID Number
Beneficiary
Relationship

Child1:
First Name
Last Name
Age
ID Number
Beneficiary:
Relationship

Child2
First Name
Last Name
Age
ID Number
Beneficiary:
Relationship

Child3
First Name
Last Name
Age
ID Number
Beneficiary:
Relationship:

By virtue of this application, I understand and agree with the insuring agreement, term of coverage, exclusions and provisions of Master Policy issued to the Policyholder.

To send this form by fax, print this form and fill in the form, thank you.

Proposer's Signature

 ...................................................................

Date

 ...................................................................
 
ICC Tel: 679-8184-91, 679-8689-90 Fax: 285-6427-8

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Revised: 11/03/00