Employee Travel Protection Plan Enrollment Form |
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| Travel Insurance Services, PC#131450 |
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IMPORTANT: As part of an employee benefit plan, it is required that all employees be enrolled in Class I, II or III. | |||||
COMPANY INFORMATION | |||||
| Company Name | ______________________________ |
Type of Business | ______________________________ | ||
| Address | ______________________________ |
Phone Number | ______________________________ | ||
______________________________ |
Fax Number | ______________________________ | |||
| Submitted By | ______________________________ |
Date | ______________________________ | ||
| Title | ______________________________ |
Email Address |
______________________________ | ||
| PREMIUM
CALCULATION | |||||
# of Employees | Rate |
Total | Please Note: Premium cannot be refunded when an employee is deleted from the plan or transfers between classes. Full annual premium will be due for transfers and added employees. | ||
Class I | ___________ | x $190 |
$ __________ | ||
Class II | ___________ | x $20 |
$ __________ | ||
Class III | ___________ | x $5 |
$ __________ | ||
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TOTAL PREMIUM DUE for Class I, II, III |
$ __________ | (Minimum annual group premium is $250.00) | |||
| CLASS I COVERAGE - WORLDWIDE TRAVEL | ||
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Name of Employee __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ |
Beneficiary __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________
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Relationship to Insured __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ Total Class I Employees ________ |
| CLASS II COVERAGE - TRAVEL IN NORTH AMERICA | ||
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Name of Employee __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ |
Beneficiary __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________
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Relationship to Insured __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ Total Class II Employees ________ |
| CLASS III COVERAGE - MINIMAL TRAVEL (During Business Hours) | ||
| Name of Employee __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ |
Beneficiary __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________
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Relationship to Insured __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ Total Class III Employees ________ |
| Send
completed Enrollment Form and check payable to Travel Insurance Services You may also fax your Enrollment Form and check to us. | ||