Worldwide Group Protector Enrollment Form

Plan Highlights Outline Rates
Travel Insurance Services, PC# 32721
Instructions
Agent Name__________________
  • Print and complete Enrollment Form. Attach the Roster of Insureds for your traveling participants.
  • Full payment must be received prior to the effective date of insurance. You may pay by check, check-by-fax, money order, MasterCard, Visa or Discover. Make check or money order for total group premium payable to Travel Insurance Services. All payments must be in U.S. dollars drawn on a U.S. bank. Do not send cash.
  • Mail with completed Enrollment Form and Roster to: Group Department, Travel Insurance Services, 2950 Camino Diablo, Suite 300, Walnut Creek, CA 94597-3991. You may fax your enrollment to 610-537-9834 when paying by credit card or check-by-fax. To avoid duplication, DO NOT mail the original enrollment form when faxing.
  • Refund of premium, less a $20 processing fee, will be returned only if a written request is received by Travel Insurance Services prior to the effective date of coverage. After the effective date of coverage, the premium is considered fully earned by the insurance company and non-refundable.
  • NOTE: Incomplete and/or incorrect applications and payments will not be processed and will be returned.
1. Group Contact
Contact Person
(responsible for purchasing insurance)		 _____________________________________
U.S. Mailing Address _____________________________________ Daytime Phone _____________________________________
City, State, Zip Code _____________________________________ Evening Phone _____________________________________
Fax Number _____________________________________ Email Address _____________________________________
(It is recommended that the contact person have access to email or a fax machine to expedite important communications.)
2. Group Information
Group Size: Minimum 3, Maximum 100. (Individuals, families or larger groups, contact TIS.)
Number of Participants _____________________________________ Group's Home Contry(ies) _____________________________________
Sponsoring Organization _____________________________________ Destination Country(ies) _____________________________________
3. Declaration
I hereby certify that all participants in the group have been listed on the attached Roster of Insureds and premium has been paid for each person and is included with this Enrollment Form. I hereby subscribe to the SunTrust Bank as Trustee of the Group Insurance Trust (District of Columbia) and enroll in the group coverage for which I am eligible under the group contract issued by The Insurance Company of the State of Pennsylvania with its principal place of business in New York, NY.
Signature _____________________________________ Title ____________________ Date ___________
Sponsoring Organization _____________________________________ Destination Country(ies) _____________________________________
4. Premium Check ONE option per group ($500 minimum group premium)  
  ___ Option A:
$16 per person, per week		 ___ Option B:
$19 per person, per week		 ___ Option C:
$22 per person, per week
5. Travel Dates If participants have different travel dates, indicate on roster.  
  Departure __________________________ (mo/day/year) Return __________________________ (mo/day/year)  
     
6. Enrollment and Payment Choose one method. See instructions for more details.  
  ___ Enroll by Mail
Payment: ___ Check ___ Credit Card
 ___ Enroll by Fax
Payment: ___ Check ___ Credit Card		  
  Credit Card Type: ___ Visa ___ MasterCard ___ Discover
  
  Card Holder Name _________________________________ Card # _________________________________ Exp. _____/_____
  Billing Address ____________________________________ Signature _______________________________ Date __________
  City, State, Zip _____________________________________