
PROTECT YOUR TICKETS, YOUR LUGGAGE, AND YOUR HEALTH, WORLDWIDE.
·
TRIP CANCELLATION
·
INTERRUPTION / DELAY
·
EMERGENCY MEDICAL AND DENTAL
·
MEDICAL TRANSPORTATION
·
LOST OR STOLEN BAGGAGE
·
MISSED CONNECTION
So you’ll be prepared. Who knows what could happen during a trip
abroad – or before you even depart. Not
only does RoundTrip help ensure you’re prepared in the event of an accident,
sickness or loss when traveling, it can even help if something causes your trip
to be cancelled.
While we’ve optimized
RoundTrip’s medical coverage for most travelers, you may determine you need
greater coverage or specific benefits.
Consider Liaison®
International or other plans from SRI for up to $5,000,000 of international
medical limits. We can create a plan that’s
right for you.
This brochure describes the
highlights of our protection plan. Plan
details and ID Card will be mailed to you once you have purchased benefits or
obtained immediate information using the online system. These details provide complete information
regarding the benefits, exclusions and limits of the protection plan. Please read it carefully. Note:
Certain terms are defined in the Evidence of Benefits that will be
mailed to you with your confirmation.
Benefit
|
Per Person Limit
|
|
Trip Cancellation |
Tour Cost to a maximum
of: $20,000 |
|
Trip Interruption |
Tour Cost to a maximum
of: $20,000 |
|
Trip Delay / Missed
Connection |
$500 |
|
Medical Expense |
$10,000 |
|
Medical Evacuation /
Repatriation |
$50,000 |
|
Lost Baggage / Personal
Effects |
$1,000 |
|
Baggage Delay |
$200 |
|
24-Hour AD&D |
$10,000 |
|
Travel Assistance Services |
Included |
|
Optional Flight Accident
per Trip |
$100,000 |
You have benefits in the
amount purchased for unused non-refundable prepaid expenses for travel
arrangements, whenever you are prevented from taking a trip for any of the
following reasons that occur after the effective date* of your protection plan:
* Effective Date is the date which begins at 12:01 a.m. following the: 1) postmark date of your enrollment form or 2) the date you fax or transmit your enrollment via the internet with the proper payment.
Trip Interruption:
If you are prevented from
completing a trip for any of the above reasons that occur after the effective
date of your protection plan and during your trip, you will receive up to the
amount purchased for:
Benefits include additional
transportation cost to join the covered trip or return home and/or for unused
non-refundable expenses for your covered trip.
Delay must be three hours or more and certified due to one of the
following reasons:
Medical Expense:
Benefits include expenses for
an accidental injury or a sickness that manifests itself during your trip, as
long as you receive initial medical treatment within 30 days after the date of
loss. Expenses will be paid for a period of 52 weeks from the date of loss. Benefits will include expenses for emergency
dental treatments, up to $750 ($750 sub limit does not apply in New York) and
advance payment to a hospital if needed to secure your admission.
Medical Evacuation /
Repatriation:
You will receive benefits if
an injury or sickness first occurs during your trip, up to the policy limit,
for medical evacuation or medically necessary repatriation to your home or a
hospital near your home for continued treatment when your condition is acute or
life threatening and adequate treatment is not available at a local
hospital. Benefits will also be paid to
return your mortal remains to your home should you die while on your trip (as
described in the Travel Assistance Service Section).
Benefits also include
transportation for the return trip home for your dependent children under age
18 who are accompanying you and are left unattended if you are confined to a
hospital for more than seven consecutive days.
Transportation will be provided for a person of your choice to visit you
if you are traveling alone and are confined to a hospital for more than seven
consecutive days. Any use of this
benefit must be pre-approved and arranged by the authorized Assistance
Company. Note: Pre-existing condition
limitations are waived for Medical Evacuation / Repatriation.
You will receive benefits
for lost, stolen or damaged luggage and personal items, as well as a lost or
stolen passport, visa and credit cards.
You also have benefits for checked luggage that is delayed or misdirected
by a common carrier for more than 24 hours from your arrival time at a
destination, other than your residence, during your trip. Benefits are payable on property not
specifically scheduled under other insurance.
Accidental Death &
Dismemberment (AD&D):
You will receive benefits
for loss of life due to an accidental injury while on your trip.
Optional Flight Accident
Plan:
These benefits apply to the
amount purchased, for accidental death, dismemberment or loss of sight as a
result of an accident while a passenger on a regularly scheduled air flight, a
land or water conveyance provided by the airline as a substitute for an
aircraft, a common carrier while en route to or from the airport, or at the
airport immediately before boarding or after disembarking from an aircraft.
Travel Assistance provides a
variety of travel related services.
Services offered include:
medical evacuation / repatriation; repatriation of remains; medical or
legal referral; hospital admission guarantee; emergency cash advance*;
translation service; prescription drug / eyeglass replacement*; passport / visa
information; bail bond*; lost baggage retrieval; inoculation information. (*payment reimbursement to the Assistance
Company is your responsibility)
"Effective Date"
is 12:01a.m. following the: postmark of your enrollment form or the date you
fax or transmit your enrollment via the Internet with the proper payment.
RoundTrip may be purchased
if you are a resident of the United States or if you purchase this plan within
the United States.
Dependent Children are
children of the Primary Applicant under 19 years of age.
Benefits are not payable for
sickness, injuries or losses of you or your traveling companion: resulting from
suicide, attempted suicide, or intentionally self-inflicted injury while sane
or insane (in Missouri, sane only; in New York, neither sane nor insane apply);
resulting from an act of declared or undeclared war; while participating in
maneuvers or training exercises of an armed service; while riding, driving or
participating in races or speed or endurance contests; while mountaineering
(engaged in the sport of scaling mountains, generally requiring the use of
picks, ropes or other special equipment; in New York, professional
mountaineering); while participating as a member of a team in an organized
sporting competition; while participating in skydiving, hang gliding, bungee
cord jumping, scuba diving or deep sea diving (in New York, professional scuba
– any sport that requires more than an “Open Water 1” certification by PADI,
NAUI, or other recognized diving certification organization); any Mental and
Nervous disorders, unless hospitalized; while piloting or learning to pilot or
acting as a member of the crew of any aircraft; received as a result or
consequence of being intoxicated or under the influence of any controlled
substance unless administered on the advice of a legally qualified physician;
to which a contributory cause was the commission of or attempt to commit a
felony or being engaged in an illegal occupation; due to normal childbirth,
normal pregnancy (except complications of pregnancy) or voluntarily induced
abortion (voluntary abortion only in New York); for dental treatment (except as
coverage is otherwise specifically provided herein); or due to a pre-existing
condition - note the pre-existing condition limitation is automatically waived
for emergency medical evacuation and medically necessary repatriation benefits,
and for benefits purchased within 10 days from the time the initial deposit is
paid on your covered trip. In
California benefits are not payable if during the 60 days prior to your effective
date, a legally qualified physician advised you or your traveling companion not
to travel due to a sickness or injury.
No benefits will be paid for expenses reimbursed or services provided by
any other source.
Pre-existing medical
conditions, as defined in the section below, will apply if you enroll in the
protection plan more than 10 days after making your initial trip deposit.
"Pre-existing
Condition" means any injury, sickness or condition (including any
condition from which death ensues) of you or your traveling companion, you
and/or your traveling companion's family member or your business partner which
within the sixty (60) day period prior to the effective date of your trip
cancellation benefits under this protection plan: a) manifested itself, became
acute or exhibited symptoms which would have caused one to seek diagnosis, care
or treatment; b) required taking prescribed drugs or medicine, unless the
condition for which the prescribed drug or medicine is taken remains controlled
without any change in the required prescription; or c) required medical
treatment or treatment was recommended by a legally qualified physician.
Note, in California, part
"(a)" of the Pre-existing Condition is not applicable.
Once you have enrolled, you
will receive an Evidence of Benefits and ID Card, which will describe all
aspects of the program, as well as who to contact in case of an emergency or if
a claim should occur. The Assistance
Company should be contacted if you require assistance while on your trip. When purchasing your trip, be sure to keep
all documentation. This information
will be required in order to process any claim.
Benefits under this plan are
provided by the American Travel Services Trust. The Trust is insured by TIG Insurance Company. In Oregon, Kansas, New York and South
Carolina the benefits of this plan are provided by a policy insured by TIG Insurance
Company.
Notice to residents of
Florida: The benefits of this plan are
provided by the American Consumer Insurance Trust. The Trust is insured by TIG Premier Insurance Company and are
governed by the law of a state other than Florida. Your homeowners policy, if any, may provide coverage for loss of
personal effects provided by the baggage and personal effects coverage. This insurance is not required in connection
with the purchase of your travel arrangements.
Notice to residents of
California: This plan contains
disability benefits or health benefits, or both, that only apply during the
covered trip. You may have coverage
from other sources that already provides you with these benefits. You should review your existing policies. If
you have any questions about your current coverage, call your insurer or health
plan. Note, in California the
pre-existing condition limitation is waived for medical expenses.
PROGRAM COSTS
Rates Effective July 1, 2002
|
Trip Cost |
Plan Rate
Per Person based on age on date of
purchase. |
|||
|
Coverage must be purchased for the full cost of the trip. |
The rates below are for trips from 1 through 30 days long. |
|||
|
|
0 to 55 |
56 to 70 |
71 to 80 |
80 and over |
|
$0 - $500 |
$33 |
$48 |
$73 |
$122 |
|
$501 - $1,000 |
$46 |
$75 |
$102 |
$171 |
|
$1,001 -
$1,500 |
$58 |
$94 |
$131 |
$219 |
|
$1,501 -
$2,000 |
$74 |
$120 |
$165 |
$278 |
|
$2,001 - $2,500 |
$100 |
$150 |
$235 |
$411 |
|
$2,501 -
$3,000 |
$115 |
$185 |
$284 |
$487 |
|
$3,001 -
$3,500 |
$129 |
$219 |
$332 |
$564 |
|
$3,501 -
$4,000 |
$144 |
$261 |
$387 |
$654 |
|
$4,001 -
$4,500 |
$164 |
$302 |
$446 |
$740 |
|
$4,501 -
$5,000 |
$183 |
$344 |
$501 |
$827 |
|
$5,001 -
$5,500 |
$263 |
$425 |
$586 |
$983 |
|
$5,501 -
$6,000 |
$288 |
$465 |
$643 |
$1,077 |
|
$6,001 -
$6,500 |
$313 |
$506 |
$698 |
$1,171 |
|
$6,501 -
$7,000 |
$342 |
$553 |
$765 |
$1,279 |
|
$7,001 -
$8,000 |
$376 |
$607 |
$839 |
$1,404 |
|
$8,001 -
$9,000 |
$424 |
$686 |
$946 |
$1,585 |
|
$9,001 -
$10,000 |
$474 |
$766 |
$1,058 |
$1,772 |
For trips of longer than 30
days, additional cost of $3 per person per day is required.
For trip cost between
$10,001 and $20,000, contact your producer or SRI for the rate.
1. Read the entire brochure and complete the Roundtrip
Application in full. Plan cost for the
entire package is due at the time of application. Remember: Benefits must be purchased for the full cost of the
trip.
2. If paying by check or money order, make payable to:
“SRI” and enclose it together with completed Application.
3. If paying by credit card, complete the Application
and mail or fax to SRI. Be sure to sign
the Method of Payment section (for all payment methods).
Return the Application with
your payment to:
SRI
9200
Keystone Crossing, Ste 300
Indianapolis,
IN 46240 USA
Fax: 317-575-2659 (credit card orders)
Phone: 800-335-0611 or 317-575-2652
Online:
www.specialtyrisk.com
(You may fax if paying by
credit card only. Originals are not
required if application is faxed to SRI with credit card payment)
|
ROUNDTRIP ENROLLMENT FORM |
|
July 1, 2002
|
Producer #
___________________________ Protection Plan may be purchased if you are a resident of the United States or if you purchase this plan within the United States. Applicant Information (First Name – Middle Name – Last Name) Primary Applicant: _____________________________ Birth Date (MM/DD/YYYY): _____ / _____ / _______ Spouse: __________________________________ Birth Date (MM/DD/YYYY): _____ / _____ / _______ Dependent Child: ___________________________ (under 19 years of age) Birth Date (MM/DD/YYYY): _____ / _____ / _______ Dependent Child: ___________________________ (under 19 years of age) Birth Date (MM/DD/YYYY): _____ / _____ / _______ Trip
Information
Departure Date (MM/DD/YYYY): ______ / ______ / ______ Return Date (MM/DD/YYYY): ______ / ______ / ______ Destination: _____________________________________ Name of Travel Supplier: __________________________ (Airline, Tour Operator, Cruise Line, etc.) Personal
Information
Your Address: ___________________________________ (must be a U.S. address) City / State / Zip: _________________________________ Phone: (____) ____________ Fax: (____) ____________ Beneficiary: ____________________________________ (For AD&D and optional Flight
Accident Coverage) In Florida, Florida Resident – Agent No. A269211 |
Rate
Calculation
Plan must be purchased for the FULL cost of trip. See rates (pg. 7).
Trip Cost Plan
Cost* Primary $ __________
= $ __________ Spouse $
__________ = $ __________ Dependent
Child $ __________ =
$ __________ Dependent
Child $ __________ =
$ __________ * Plan
costs must be indicated for all travelers. For Trips
of 31 – 90 Days. Include departure
& return dates in calculation. $3 x _________ x _________ =
$ __________ # of Days Over 30 Total # of Travelers Optional
Flight Coverage (Maximum $100,000 / person) $100,000
Protection for $10 x ________
= $ __________
Total # of Travelers Non-Refundable
Processing Fee = $ 5.00 Total Amount Due = $ __________
And authorized as payment below. Method
of Payment ڤ
Check / Money Order Payable to SRI ڤ
Visa ڤ MasterCard ڤ Discover/Novus ڤ Diners Club Signature is required below for all
methods of payment. CC
Number: ___________________________________ Expiration
Date: _______ Daytime Phone:
___________ Name on
Card: __________________________________ Any person
who, with intent to defraud or knowing that he/she is facilitating a fraud
against an Insurer, submits an application or files a claim containing a
false or deceptive statement is guilty of insurance fraud. Plan costs are non-refundable after 10-day
review period. ____________________________________ _________ Signature:
mandatory for all payment options.
Date |