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Primary Insured Information

	Passenger #1:	Passenger #2:	Passenger #3:	Passenger #4:
Trip Cost:
Age:
First Name:
Last Name:
Sex:
Date of Birth: (MM/DD/YYYY)
Employer:
Telephone (home):

Beneficiary (optional)

First Name:
Last Name:
Sex:

Trip Details

Departure: (MM/DD/YYYY)
Return: (MM/DD/YYYY)
Initial Trip: (MM/DD/YYYY)

Payment

Total Amount to be Paid:

Credit Card Type:

MasterCard

Visa

Amex

Discover/Novus

Cardholder:

Credit Card Number:

Credit Card Expiration Date (MM/YY):

Method of Delivery:

	US Postal Service - fulfillment package is delivery within 7-10 days via USPS.
	Express add $12 - fulfillment package is delivery next business day if policy is purchased before 2pm CST. (US only)

Please Read Before Submitting
I represent that the above information is true and the dates are accurate. The policy goes into effect at 12:01am on the day after the receipt, postmark, telephone purchase or fax transmission date to Travel Guard. We reserve the right to reject an application.
I understand that certain medical conditions are not covered. I have read the Schedule of Coverage and agree to its terms and conditions.
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any fact thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Application may be mailed, phoned, sent electronically, or faxed in up to 72 hours prior to departure. Insurance may be purchased by anyone residing in the U.S. at the time of purchase or by Canadian residents providing they are booking through a U.S. Travel Agent.
If you experience trouble in submitting this application, please call (415) 564-4353 , and our Customer Service Department will be happy to assist you.