Water's
Edge
Travel
Insurance
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Procedure] [Rental
Agreement] [Pet
Policy]
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TRAVEL
INSURANCE ENROLLMENT FORM.
-
Complete
Parts I through IV of this enrollment form. Incomplete
or incorrect enrollment forms and payments will be returned,
unprocessed.
-
Calculate
Your Premium:
Premium rates are per person based upon your age and
cost of your trip. Select your premium from the
correct column in the Premium Rate Table. For
Trips over 30 Days (up to 90 days in total),
there is an additional premium charge of $5.00 per person
per day. You must indicate in Item II of the Enrollment
Form the types of prepaid travel arrangements you are
insuring... air, land, cruise and/or other. You
should insure 100% of those arrangements that have any
cancellation penalty or restrictions. If
you insure a lesser amount, the exclusion for Pre-Existing
Conditions will not be waived and the Trip Cancellation
and Trip Interruption Benefits will be limited to the
amount of coverage you purchased.
-
Premium
Payment: Please print this form and fill it out completely,
then fax it to: (407) 359-8829 or mail
it to: Sun N' Surf Vacation Rentals, 1324 Tall
Maple Loop, Oviedo, FL 32765.
-
IMPORTANT:
After enrolling, you will receive your Travel
Insurance Certificate which is your evidence
of coverage under the plan.
.
I.
Travel Information
Agency/Agent
Name: Sun N' Surf Vacation Rentals
Travel
Agency Code:
LAUFL02
Departure
Date__________________: Return
Date:
Total
Trip Days (includingdeparture/returndates):______________________________
Travel
Destination:______________________________________________________
.
Indicate
below the types of travel arrangements you are insuring:
_______ Air
Airline ___________________________________
_______
Land
Travel Supplier ____________________________
_______
Cruise
Cruise line _______________________________
_______ Other
_______________________________________
.
II.
Participant(s) – All
Information Below Is Required
.
Eligibility
Notice:
This plan is only available to citizens or residents of
the U.S. or Canada. Eligibility for purchase will
be confirmed on all claims. If it is determined
that a person is not a citizen or resident of the U.S.
or Canada, his or her claim will be denied and premium
will be refunded.
.
To
calculate the Trip Cost per Person, take the total cost
of Water’s Edge rental fees that are non-refundable
and divide that amount by the number of travelers, add
any other non-refundable fees, such as airline tickets,
etc. That total will reflect the Trip Cost
per Person as shown on the Rate Table below. Fill
out a separate Travel Insurance Enrollment
form for each household that is purchasing travel insurance.
.
Name
Gender Present
Age Trip Cost/Person
.
1.
__________________________
______
______
________________
2.
__________________________
______
______
________________
3.
__________________________ ______
_____
________________
4.
_________________________
______
______
________________
5. __________________________
______
______
________________
6.
_________________________
______
______
________________
7.
__________________________
______
______
________________
8.
__________________________
______
______
________________
9.
__________________________
______
______
________________
10.
__________________________
______
______
________________
11.
__________________________
______
______
________________
12.
___________________________
______
______
________________
.
Beneficiary(ies):
The Insured’s Estate (unless otherwise designated)
.
III.
Payment Calculation
Premium
Rate Table (For trips less than 30 days)
Trip
Cost Per Person |
Up
to Age 35 |
Age
36 to 50 |
Age
51 to 62 |
Age
63 to 72 |
Age
73 to 79 |
Age
80 & over |
Up
to $500 |
$28 |
$34 |
$40 |
$50 |
$68 |
$88 |
$501
to $1,000 |
$34 |
$45 |
$50 |
$68 |
$102 |
$129 |
$1,001
to $1,500 |
$45 |
$56 |
$85 |
$113 |
$158 |
$188 |
$1,501
to $2,000 |
$62 |
$79 |
$118 |
$158 |
$215 |
$258 |
$2,001
to $2,500 |
$79 |
$102 |
$152 |
$203 |
$271 |
$328 |
$2,501
to $3,000 |
$96 |
$124 |
$186 |
$249 |
$328 |
$398 |
$3,001
to $3,500 |
$113 |
$146 |
$220 |
$294 |
$384 |
$468 |
$3,501
to $4,000 |
$136 |
$170 |
$254 |
$339 |
$440 |
$538 |
$4,001
to $4,500 |
$158 |
$192 |
$288 |
$384 |
$498 |
$608 |
$4,501
to $5,000 |
$181 |
$214 |
$322 |
$429 |
$554 |
$680 |
$5,001
to $5,500 |
$204 |
$238 |
$356 |
$475 |
$610 |
$750 |
$5,501
to $6,000 |
$226 |
$260 |
$390 |
$520 |
$666 |
$819 |
$6,001
to $6,500 |
$248 |
$282 |
$424 |
$565 |
$724 |
$890 |
$6,501
to $7,000 |
$270 |
$306 |
$458 |
$610 |
$780 |
$960 |
$7,001
to $7,500 |
$294 |
$328 |
$492 |
$655 |
$836 |
$1,030 |
$7,501
to $8,000 |
$316 |
$350 |
$525 |
$700 |
$894 |
$1,100 |
$8,001
to $8,500 |
$340 |
$372 |
$560 |
$746 |
$950 |
$1,170 |
$8,501
to $9,000 |
$360 |
$396 |
$594 |
$790 |
$1,006 |
$1,240 |
$9,001
to $9,500 |
$384 |
$418 |
$628 |
$836 |
$1,062 |
$1,310 |
$9,501
to $10,000 |
$406 |
$440 |
$664 |
$880 |
$1,120 |
$1,380 |
TravelSafe
Base
Premium
(From
Age Rate Table) |
|
Additional
Premium for Trips Over 30 Days
($5.00/Day
x No. Days Over 30 Days) |
|
Total
Base Premium |
Premium
Factor Cancel For Any Reason Option
(Use
Only if buying option) |
|
Total
Payment
(Round
to nearest dollar) |
1.
$ ____________ |
+
|
$____________
|
=
|
____________
|
X
1.40 |
=
|
$____________
|
2.
$____________ |
+
|
$____________
|
=
|
____________
|
X
1.40 |
=
|
$____________
|
3.
$____________ |
+
|
$____________
|
=
|
____________
|
X
1.40 |
=
|
$____________
|
4.
$____________ |
+
|
$____________
|
=
|
____________
|
X
1.40 |
=
|
$____________
|
5.
$____________ |
+
|
$____________
|
=
|
____________
|
X
1.40 |
=
|
$____________
|
6.
$____________ |
+
|
$____________
|
=
|
____________
|
X
1.40 |
=
|
$____________
|
7.
$____________ |
+
|
$____________
|
=
|
____________
|
X
1.40 |
=
|
$____________
|
8.
$____________ |
+
|
$____________
|
=
|
____________
|
X
1.40 |
=
|
$____________
|
9.
$____________ |
+
|
$____________
|
=
|
____________
|
X
1.40 |
=
|
$____________
|
10.
$___________ |
+
|
$____________
|
=
|
____________
|
X
1.40 |
=
|
$____________
|
11.
$___________ |
+
|
$____________
|
=
|
____________
|
X
1.40 |
=
|
$____________
|
12.
$___________ |
+
|
$____________
|
=
|
____________
|
X
1.40 |
=
|
$____________
|
Subtotal
for all Participants
_____________
Non-Refundable Enrollment Processing Fee
(required) $
5.00
Total Premium Payable to TravelSafe
______________
.
Form
of Payment: AMEX
Discover
MasterCard
Visa
Card
Number_______________________________________________________
Validation
Code_____________
Expiration Date________ /________
.
You
will find the validation code (last
3 digits) at the end of the signature strip on the back
of the card if using Discover, MasterCard or Visa.
For American Express, the number (4 digits) is on the front
of the card above and to the right of the card number.
.
Cardholder
Name __________________________________________________________
Cardholder
Address ________________________________________________________
City
_______________________________________________________________
State
_____________ Zip Code __________________
.
I
authorize TravelSafe to charge my credit card for
the total premium.
.
Cardholder
Signature:
________________________________________________________
.
IV.
Primary Traveler Name/Address
.
First
Name ________________________________________
M.I. ________________
Last
Name ______________________________________________________________
Address
_________________________________________________________________
C_ity
______________________________ State _______
Zip Code ________________
Phone(Day)
_______________________ Phone(Eve) ____________________________
Fax________________________________Email_________________________________
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Traveler's Insurance Form |
