High Limit Accident Insurance Application

Plan Highlights Outline Instructions
Travel Insurance Services, PC# 32701
Agent PC# (if different from above) ________
 
Proposed Insured:
First:___________________________Middle:_______________Last:___________________________
Residence Address:

Street and Number:____________________________________________________________________

City:_________________________ State:_________ Zip:_______________

Daytime Phone Number: (_________) ___________ - ___________

Fax Number: (_________) ___________ - ___________

Personal Information:

Date of Birth: Month:__ __/Day:__ __/Year:__ __ __ __ Height:______ Weight:______

E-mail Address: _________________________________________

Occupation:

 _______________________________ Annual Earnings: ______________________________
Purpose of Insurance: ____________________________________________________________________

Other Insurance:

Please indicate the total amount of life insurance benefits in force or applying for $ __________________
Geographical Limits:
 Please indicate countries to be visited if outside of the U.S.A.: ____________________________________
Air Travel:

Will aviation travel be on regularly scheduled airlines? If "no," please provide details. Yes No

_______________________________________________________________________
Name of Beneficiary:

____________________________ Relationship:________________________________

Address:
 _______________________________________________________________________
Policy Owner:

____________________________ Relationship:________________________________

Address:
 _______________________________________________________________________
Benefit Requested:
 Sum Insured $ _____________ (Not to exceed 10 times annual income or satisfactory justification must be submitted)
Coverage Requested:
(check one)
All-Risk/24Hr or Common Carrier or Air Travel Only
Optional Coverage:
 War or Acts of War and Terrorism
Benefits Requested:

(check one)
Accidental Death (AD) Accidental Death and Dismsmberment (AD&D)

Accidental Death, Dismsmberment and Sudden Cardiac Arrest (AD&D + SCA up to age 65)

Period of Insurance:
 Number of Days: __________________________ Effective Date: ___________________________
Please Answer All The Questions
1) Have you any physical defect of infirmity? Yes No5) Have you ever been declined or accepted on special terms for life, accident or illness insurance? Yes No
2) Is your sight or hearing defective? Yes No6) Do you intend to engage in hazardous sports or any other pastimes that expose you to extra personal injury? Yes No
3) Have you ever suffered from any nervous or mental condition, fainting episode, blackout, fit or paralysis of any kind? Yes No   

4) Have you ever suffered from:

Dates and Details to all "YES" answers above:

_____________________________________________________

_____________________________________________________

_____________________________________________________

 

USI 01/06

a) high blood pressure, a heart condition, rheumatic fever or diabetes? Yes No
b) a "slipped disc" of other spinal disorder, a hernia or any rheumatic or arthritic condition? Yes No
Declaration
I declare that the above statements are true and complete, and that, apart from the matters declared above, I am in good health and ordinarily enjoy good health. I agree to the Underwriters obtaining medical information from any doctor or hospital who has attended me and authorized such doctor or hospital to provide this information. I agree that this proposal shall form the basis of the contract should the insurance be effected and any misstatements above may be grounds for recision. I understand that pre-existing conditions are not covered until a period of insurance, treatment free, has elapsed.
Date: ___________________________________________ ________________________________________________
Signature of Proposed Insured
Owner:__________________________________________
(if other than proposed insured)		 ________________________________________________
(Signature of Owner or Title and signature of Officer signing for Firm or corporation)
Phone: _____________________________ Applicant's Fax: _____________________________ Applicant's E-mail: _____________________________

Authorization To Release Personal Information (HIPPA Compliant)

I AUTHORIZE any physician, medical practitioner, hospital, clinic, health care facility, other medical or medically related facility, insurance or reinsuring company, consumer reporting agency, employer having information available as diagnosis, treatment, and prognosis with respect to any physical or mental condition and/or treatment of me or my minor children to provide to Petersen International Underwriters, Inc., or to any agency authorized by Petersen International Underwriters, Inc to collect any and all such information by means of U.S. Post , fax or e-mail.

I AUTHORIZE Petersen International Underwriters to communicate with me/us or our representative via mail, phone, fax or electronic mail regarding quotations, underwriting, claims, coverage administration, or additional coverages from Petersen International Underwriters.

I UNDERSTAND the purpose of this Authorization is to allow Petersen International Underwriters, Inc., to determine eligibility for life or health insurance or claim for benefits under a life or health policy. Any information obtained will not be released by Petersen International Underwriters, Inc., to any person or organization EXCEPT to those persons or organizations needing such information in performing business or legal services in connection with my application, claim or as may be otherwise lawfully required or as I may further authorize.

I KNOW that I may request to receive a copy of this Authorization.

I UNDERSTAND that I may revoke this Authorization, except to the extent that Petersen International Underwriters, Inc. has acted in reliance upon this Authorization. My revocation must be submitted in writing to Petersen International Underwriters Inc Any such revocation may also have an impact upon my Underwriting or claims processing.

I UNDERSTAND that I can obtain a complete copy of Petersen International Underwriters Inc. Privacy Policy either on Petersen International Underwriters, Inc. website or by contacting them directly and asking for a copy.

I AGREE that a photostatic copy of this Authorization shall be as valid as the original.

I AGREE this Authorization shall be valid for two years from the date shown below.

Signed this _______day of ______________20________ Signature of Proposed Insured ________________________________

Please read Petersen International Underwriter's Privacy Policy.

 

Instructions

  1. Read and understand the High Limit Accident Insurance Highlights, Outline before applying for coverage.
  2. Print this application and complete hard copy (both pages). Complete one application per person. Please print neatly or type.
  3. Residents of California only, please print and complete Form D-1 also. (PDF format, 2 pages, 200kb.)
  4. Fax the completed application to our office, (925) 932-1820, in order to obtain a quote. A quote will be returned to you in approximately 2-3 business days.

Once you have received a quote, to purchase a policy:

  1. Make full premium check or money order payable to the plan administrator, Petersen International Underwriters. All payments must be in U.S. dollars drawn on a U.S. bank. Do not send cash.
  2. Mail your completed application with original signatures and full premium payment to:
    Travel Insurance Services
    2950 Camino Diablo, Suite 300
    Walnut Creek, CA 94597-3991 USA
  3. The original application and full premium payment must be received by our office prior to policy release.

Please Note:

The maximum principal sum benefit cannot exceed 10 times one's annual income, or satisfactory justification must be submitted. If you are an unemployed and basing your income on your spouse's income, the maximum principal sum benefit available to you is $1,000,000.

Underwriting time is normally 3-5 business days from 1) the date Travel Insurance Services (TIS) receives a copy of the completed application by fax.

The earliest effective date available is the day of the underwriter's approval.

A Certificate of Insurance will be sent to you by first class mail. Upon receipt of your Certificate of Insurance, please read it carefully as the terms and conditions stated therein will prevail.

This product is not available in the states of NY, RI, and IA.

Questions?

Contact: Yvonne Lee or Sandy Franchebois

Fax: (925) 932-1820
Phone: (800) 937-1387 or (925) 932-1387

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