Water's Edge                                             

Travel Insurance

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TRAVEL INSURANCE ENROLLMENT FORM.

1. Complete Parts I through IV of this enrollment form.  Incomplete or incorrect enrollment forms and payments will be returned, unprocessed.
2. 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.
3. 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.
4. IMPORTANT: After enrolling, you will receive your Travel Insurance Certificate which is your evidence of coverage under the plan.

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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:______________________________________________________

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Indicate below the types of travel arrangements you are insuring:

           _______   Air                           Airline ___________________________________

_______   Land                        Travel Supplier ____________________________

_______   Cruise                      Cruise line _______________________________     _______   Other                       _______________________________________

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II.      Participant(s) – All Information Below Is Required

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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.

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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.

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Name                                     Gender        Present Age   Trip Cost/Person

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1. __________________________       ______                 ______                 ________________

           2. __________________________       ______                 ______                 ________________

3. __________________________       ______                  _____                 ________________

4. _________________________         ______                 ______                 ________________

          5. __________________________       ______                  ______                 ________________

6. _________________________        ______                   ______                 ________________

7. __________________________       ______                  ______                 ________________

          8. __________________________       ______                   ______                 ________________

          9. __________________________       ______                   ______                 ________________

        10. __________________________        ______                  ______                 ________________

        11. __________________________       ______                   ______                 ________________

           12. ___________________________     ______                   ______                 ________________

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Beneficiary(ies): The Insured’s Estate (unless otherwise designated)

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III.     Payment Calculation       

Premium Rate Table (For trips less than 30 days)

                                                                                       Subtotal for all Participants _____________

                       Non-Refundable Enrollment Processing Fee (required)        $ 5.00                                                           Total Premium Payable to TravelSafe ______________

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Form of Payment:             AMEX               Discover              MasterCard              Visa

Card Number_______________________________________________________    

Validation Code_____________              Expiration Date________ /________

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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.

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Cardholder Name __________________________________________________________

Cardholder Address ________________________________________________________

City _______________________________________________________________

State _____________ Zip Code __________________

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I authorize TravelSafe to charge my credit card for the total premium.

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Cardholder Signature: ________________________________________________________

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IV.     Primary Traveler Name/Address

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First Name ________________________________________   M.I. ________________

Last Name ______________________________________________________________

Address _________________________________________________________________

C_ity ______________________________ State _______ Zip Code ________________

Phone(Day) _______________________ Phone(Eve) ____________________________

Fax________________________________Email_________________________________

Click here to Print Traveler's Insurance Form