Cancel for Medical Flight Guard®
Any Reason Coverage $100,000 = $9 | $200,000 = $18
2 Faith Travel PLAN COST CALCULATION Multiply Base Plan
Cost by 1.4
Upgrade $300,000 = $27 | $400,000 = $36
$500,000 = $45
DATE OF PLAN COST
INSURED NAME BIRTH TRIP COST – BASE OPTIONAL COVERAGES
#
1 / / + + =
#
FAITH TRAVEL Travel Insurance 2* / / + + =
ENROLLMENT FORM 008543 #
3* / / + + =
1 Enrollment #
4* + + =
/ /
INSURED #1:
$
*For children 17 and under related to the primary adult, please list their name, date
of birth, and trip cost only. If optional coverages are selected the appropriate plan cost
Optional Car Rental Collision 9 x =
*Last will apply.
Coverage ($9 per day per car) Per Day # of days
$
*First *Middle Initial
+ 7
*Date of Birth SERVICE FEE
Trip Cost Per Person AGE
*Address (up to 30 days) 0-34 35-59 60-69 70-74 75-79 80-84 85+ 3 T O TA L
*Address $ 0 $ 19 $ 29 $ 37 $ 49 $ 61 $ 97 $ 103
Any person who knowingly and with intent
$ 1- $ 250 $ 23 $ 32 $ 38 $ 52 $ 63 $ 100 $ 109
defrauds any insurance company is subject to
*City $ 251 - $ 500 $ 25 $ 36 $ 41 $ 54 $ 65 $ 104 $ 120 criminal and civil penalties. I represent that the
$ 501 - $ 1,000 $ 41 $ 52 $ 66 $ 91 $ 112 $ 163 $ 182 above information is true and the dates reflect my
*State *Zip $ 1,001 - $ 1,500 $ 53 $ 71 $ 91 $ 124 $ 158 $ 217 $ 258 intent to start and end my trip. The coverage goes
$ 1,501 - $ 2,000 $ 72 $ 95 $ 125 $ 175 $ 216 $ 280 $ 331 into effect after the premium is paid, at 12:01 a.m.
*Telephone ( )
$ 2,001 - $ 2,500 $ 92 $ 120 $ 155 $ 257 $ 308 $ 342 $ 403
on the day after the postmark, telephone
purchase, fax transmission date, or online
Beneficiary $ 2,501 - $ 3,000 $ 111 $ 141 $ 184 $ 333 $ 383 $ 404 $ 476 purchase confirmation date. The Insurer reserves
$ 3,001 - $ 3,500 $ 130 $ 150 $ 215 $ 373 $ 429 $ 469 $ 553 the right to reject any Enrollment Form. I
*Destination Country $ 3,501 - $ 4,000 $ 148 $ 164 $ 244 $ 414 $ 455 $ 580 $ 632 understand there is no coverage for loss due to
$ 165 $ 187 $ 308 $ 445 $ 490 $ 616 $ 693 pre-existing medical conditions, unless this
$ 4,001 - $ 4,500
insurance is purchased within the required time
*Airline $ 4,501 - $ 5,000 $ 184 $ 209 $ 346 $ 476 $ 524 $ 697 $ 765 frame to waive this exclusion. I understand that if
$ 5,001 - $ 5,500 $ 211 $ 247 $ 380 $ 507 $ 560 $ 821 $ 894 payment is returned unpayable for any reason, the
*Charter $ 5,501 - $ 6,000 $ 239 $ 284 $ 414 $ 538 $ 590 $ 850 $ 925 coverage becomes null and void. I also understand
$ 6,001 - $ 6,500 $ 260 $ 311 $ 451 $ 573 $ 637 $ 905 $ 985 that any changes to this Enrollment Form do not
*Tour Operator $ 6,501 - $ 7,000 $ 281 $ 337 $ 489 $ 618 $ 684 $ 964 $ 1,057 change the coverage of the policy. I have read,
understand, and agree to the terms and conditions
$ 7,001 - $ 8,000 $ 309 $ 368 $ 551 $ 705 $ 878 $ 1,171 $ 1,274
*Cruise Line $ 347 $ 399 $ 614 $ 798 $ 995 $ 1,336 $ 1,454
of the Insurance as detailed in the Description of
$ 8,001 - $ 9,000 Coverage.
*Date of Initial Trip Payment / / $ 9,001 - $10,000 $ 384 $ 429 $ 675 $ 880 $ 1,118 $ 1,498 $ 1,629
$10,001 - $ 11,000 $ 441 $ 496 $ 764 $ 978 $ 1,236 $ 1,656 $ 1,800
*Departure Date / / *Return Date / / $11,001 - $12,000 $ 498 $ 562 $ 840 $ 1,090 $ 1,352 $ 1,812 $ 1,972 Signature
$12,001 - $13,000 $ 555 $ 630 $ 910 $ 1,199 $ 1,470 $ 1,970 $ 2,154
$13,001 - $14,000 $ 615 $ 698 $ 992 $ 1,307 $ 1,597 $ 2,127 $ 2,349
Date
AGENCY ARC# Agent ID# $14,001 - $15,000 $ 676 $ 769 $ 1,074 $ 1,415 $ 1,756 $ 2,285 $ 2,543
*Required information. Medical Coverage Upgrade $ 13 $ 18 $ 24 $ 32 $ 42 $ 54 $ 65 To Purchase: Contact your travel
agent or complete and mail in this
4 PAYMENT INFORMATION Check or Money Order Payable to Travel Guard American Express® MasterCard® VISA® Discover/Novus® application form to:
3300 Business Park Drive
Stevens Point, WI 54482
| | | | | | | | | | | | | | | | Expires / Name of Cardholder
12/2/10
