To purchase ProtectAssist: Determine
STEP #1 the individual trip cost for each person
you want to insure, and calculate the total premium
using the rates on pages 5-6.
STEP #2 To purchase Additional Coverages
desired: Select the level of Flight Guard®
coverage you wish to purchase on the enrollment form,
and multiply the corresponding cost by the number of
persons you wish to insure under the policy. Calculate
the total premium. Select Umbrella Package and
determine the appropriate premium on the enrollment
form based on the age of each Insured. Calculate the
total premium. Select the number of days of Renter’s
Collision Insurance. Calculate the premium.
Add together all the premium boxes
STEP #3 for your total travel insurance package.
Fill out attached Enrollment
STEP #4 Form on the next page.
Fill out the Payment Information
STEP #5 section of the enrollment form and
return the enrollment form to your
If you have questions or
would like to order by phone, call:
You can also purchase this valuable
coverage on our web site at:
1145 Clark Street; Stevens Point, WI 54481
STEP #1 ProtectAssist® STEP #4 ENROLLMENT FORM (Please print carefully)
INSURED #1 INSURED #2 INSURED #3 INSURED #4
Trip Cost Trip Cost Trip Cost Trip Cost *Insured #1 q Dr. q Mr. Last q Female
First Middle Initial
Premium Premium Premium Premium
*Date of Birth E-mail Address
+ + + *Address
Total of all premiums TOTAL *City *State *Zip
= *Telephone ( ) Beneficiary
STEP #2 ADDITIONAL COVERAGES
Optional Umbrella Package:
(Cannot be purchased without ProtectAssist.)
*Tour Operator *Cruise Line
Age 0-34 35-59 60-69 70-74 75-79 80-84 85+
Premium $12 $17 $22 $30 $39 $50 $60 *Date of Initial Trip Payment / / *Departure Date / / *Return Date / /
INSURED #1 INSURED #2 INSURED #3 INSURED #4
AGENCY ARC# Agent ID#
Premium Premium Premium Premium
For trips over 30 days, please call Travel Guard for a premium quote.
+ + + Additional Insureds
Insured #2 *Date of Birth
Total of all premiums TOTAL Relationship to Insured #1:
= Insured #3 *Date of Birth
Relationship to Insured #1:
Insured #4 *Date of Birth
0 Flight Guard Relationship to Insured #1: * =Required Information
Benefit $100,000 $200,000 $300,000 $400,000 $500,000
Any person who knowingly and with intent defrauds any insurance company is subject to
Premium $9 $18 $27 $36 $45
criminal and civil penalties. I represent that the above information is true and the dates STEP #5 PAYMENT INFORMATION
reflect my intent to start and end my trip. The coverage goes into effect after the premium is
Premium # of persons TOTAL Check or Money Order Payable to Travel Guard
x + 3 =
paid, at 12:01 a.m. on the day after the postmark, telephone purchase, fax transmission date, or
online purchase confirmation date. The Insurer reserves the right to reject any Enrollment
Form. I understand there is no coverage for loss due to pre-existing medical conditions,
American Express® MasterCard®
unless this insurance is purchased within the required time frame to waive this exclusion. VISA ®
I understand that if payment is returned unpayable for any reason, the coverage becomes
Renter’s Collision Insurance: Coverage is $9 per car, per day.
null and void. I also understand that any changes to this Enrollment Form do not change
the coverage of the policy. I have read, understand, and agree to the terms and conditions
x x x x x x x x x x x x x x x x
3 (Not available to Oregon or Texas residents.) of the Insurance as detailed in the Description of Coverage. x
Premium # of days TOTAL Expires /
9 x + $
= Signature Date
To purchase, contact your travel agent. Order online or by phone, 24 hours a day, 7 days a week.
STEP #3 TOTAL PREMIUM $ www.TravelGuard.com 1.800.549.9037
of ProtectAssist® and Additional Coverages
“911” Emergency Travel Assistance Comprehensive Travel Insurance
The Plan can arrange for an
emergency cash advance and The Plan will reimburse
help you obtain a new passport your nonrefundable deposits
when your important travel or pre-payments when your
documents are stolen.* sister becomes ill and you
have to cancel your trip.*
The Plan will cover your lost expenses when you’re
forced to cancel your trip because a terrorist incident
just occurred in the city to which you’re scheduled to
The Plan will replace travel within 30 days of your planned arrival.*
the medication that was
in your lost luggage.*
The Plan will help locate your
lost or delayed luggage; plus,
The Plan will get your family we’ll reimburse you for the
home when you arrive at necessities you have to purchase
the airport at 10 p.m. only to until your baggage arrives.*
find your flight is cancelled.*
The Plan will reimburse
The Plan will coordinate an your nonrefundable deposits
emergency medical evacuation and get you home if your
and find adequate medical cruise line, airline, or tour
care when you are involved operator cannot due to
in an accident or Financial Insolvency.*
become suddenly ill.*
*Subject to terms and conditions of the policy.
24-Hour Emergency Travel Insurance Coverages
& Medical Services* All coverages are per person.
TRAVEL COVERAGE SCHEDULE OF BENEFITS
• LiveTravel – 24-hour travel agent for GUARD Trip Cancellation Trip Cost*
emergency or last-minute travel changes,
such as rebooking flights, hotel
Exclusive Trip Interruption Trip Cost*
reservations or ground transportation, Trip Interruption – $1,000**
tracking lost luggage, and more!
• Pre-trip travel advice – access to passport, visa, and vaccine
Return Air Only
requirements, travel safety and health advisories, embassy Travel Delay $1,500
contacts, weather, and currency information. (Maximum of $150 per day)
• Emergency medical assistance – locating English-speaking Missed Connection $250
medical specialists or facilities and assistance with medical
evacuations anywhere in the world. Baggage & Personal $750
• E-mail or phone message relay – to family, friends, and Effects Loss
business associates. (Includes lost, stolen, or damaged
• Cash advance – for general travel and medical emergencies. luggage or travel documents)
• Replacing lost travel documents – such as tickets, passport, Baggage Delay $250
• Telephone interpretation – for medical or legal emergencies. Medical Expense $25,000
• Bag Trak® – luggage-tracing service. Emergency Medical $500,000
*Coverage only included if the required premium has been paid.
Concierge Services* **Coverage valid for $0 Trip Cost option only.
• Restaurant referrals/reservations – Worldwide dining referrals
When you purchase ProtectAssist travel insurance within 15
and reservations made on your behalf; based on availability.
days* of making your initial trip deposit, you also receive:
• Ground transportation – Coordinating car or limo arrangements
throughout your trip, including transportation to and from • Coverage in the event of cruise line, airline, and tour
airport, hotel, meetings, and more. operator financial default. (Financial default is not
• Event ticketing – Assistance with obtaining tickets to sporting, covered for all suppliers.)
theater, concert, and other events; based on availability. • Waiver of Pre-existing Medical Condition Exclusion.
• Tee time reservations – Assistance with scheduling tee times • Missed Connection Benefit increases to $500.
and making course recommendations; based on availability. • $50,000 Flight Guard (This coverage is in addition to any
• Floral services – Coordination of flower delivery for birthdays, Additional Flight Guard that is purchased.)
anniversaries, holidays, and other special occasions while *Day one is the date the trip deposit is received.
*These are not insured benefits. Rather, they are services
provided by Travel Guard and its member companies. OPTIONAL UMBRELLA PACKAGE
Valuable additions available for an affordable fee.
Medical Expense and Emergency Medical
SATISFACTION GUARANTEE Transportation benefits are double those listed on the
Travel Guard is committed to providing products and services Schedule of Benefits and Medical coverage is upgraded to
that will exceed expectations. If You are not completely primary coverage. (Cannot be purchased without ProtectAssist.)
satisfied, You can receive a refund of the premium, minus the
service fee(s). Requests must be submitted to Travel Guard in Flight Guard® – Accident coverage up to $500,000 –
writing within 15 days of the effective date of coverage, for you and your family, if insured, while flying.
provided it is not past the original departure date. Renter’s Collision Insurance – $35,000 in primary
coverage. Covers collision damage to a rental car for which
the car rental contract holds you responsible.
page 3 page 4
Insurance Protection Rates
Trip Cost Per Person AGE AGE
(up to 30 days) 0-34 0-34 35-59 60-69 70-74 75-79 80-84 85+
$ 0* $ 16 $ 24 $ 29 $ 35 $ 53 $ 65 $ 79
$ 1- $ 500 $ 24 $ 36 $ 40 $ 51 $ 60 $ 91 $ 102
$ 501 - $ 1,000 $ 41 $ 52 $ 65 $ 89 $ 108 $ 139 $ 172
$ 1,001 - $ 1,500 $ 53 $ 71 $ 89 $ 117 $ 154 $ 183 $ 242
$ 1,501 - $ 2,000 $ 72 $ 94 $ 123 $ 166 $ 201 $ 238 $ 311
$ 2,001 - $ 2,500 $ 92 $ 118 $ 152 $ 205 $ 248 $ 294 $ 381
$ 2,501 - $ 3,000 $ 111 $ 139 $ 181 $ 245 $ 295 $ 347 $ 453
$ 3,001 - $ 3,500 $ 130 $ 148 $ 211 $ 284 $ 340 $ 402 $ 522
$ 3,501 - $ 4,000 $ 148 $ 162 $ 240 $ 323 $ 388 $ 467 $ 592
$ 4,001 - $ 4,500 $ 165 $ 185 $ 303 $ 362 $ 434 $ 528 $ 662
$ 4,501 - $ 5,000 $ 184 $ 206 $ 340 $ 401 $ 481 $ 590 $ 731
$ 5,001 - $ 5,500 $ 211 $ 244 $ 374 $ 472 $ 528 $ 662 $ 802
$ 5,501 - $ 6,000 $ 237 $ 281 $ 407 $ 516 $ 575 $ 733 $ 873
$ 6,001 - $ 6,500 $ 258 $ 307 $ 444 $ 561 $ 621 $ 801 $ 943
$ 6,501 - $ 7,000 $ 279 $ 333 $ 481 $ 605 $ 667 $ 869 $1,012
$ 7,001 - $ 8,000 $ 307 $ 362 $ 540 $ 684 $ 762 $ 977 $1,155
$ 8,001 - $ 9,000 $ 345 $ 392 $ 598 $ 764 $ 856 $1,084 $1,295
$ 9,001 - $10,000 $ 382 $ 422 $ 659 $ 842 $ 953 $1,192 $1,439
$10,001 - $11,000 $ 438 $ 491 $ 752 $ 958 $1,118 $1,391 $1,680
$11,001 - $12,000 $ 495 $ 556 $ 827 $1,068 $1,261 $1,569 $1,893
$12,001 - $13,000 $ 552 $ 623 $ 896 $1,175 $1,408 $1,752 $2,081
$13,001 - $14,000 $ 611 $ 691 $ 977 $1,281 $1,558 $1,940 $2,269
$14,001 - $15,000 $ 672 $ 761 $1,058 $1,387 $1,713 $2,132 $2,457
OPTIONAL UMBRELLA $12 $17 $22 $30 $39 $50 $60
*Includes $1,000 Trip Interruption – Return Air Only.
**If appropriate additional premium has been paid.
Please choose your premium from the above
Above rates do not include a $6 service fee. pricing chart based on your age at the
A $3 service fee applies to any additional coverage purchased. time of insurance purchase.
For trips over $15,000, or trips exceeding
30 days, call 1.800.549.9037.
Coverage must be purchased at least
24 hours prior to departure.
1145 Clark Street
Stevens Point, WI 54481
www.TravelGuard.com YOU MUST INSURE THE PRE-PAID
NON-REFUNDABLE PORTIONS OF YOUR TRIP.
page 5 page 6
This is a brief description of insurance coverages. The policy contains “Immediate Family Member” means the Insured’s or Traveling
reductions, limitations, exclusions, and termination provisions. A Companion’s spouse, Domestic Partner, child, spouse’s child,
Description of Coverage detailing all coverages will be issued to you daughter-in-law, son-in-law, brother, sister, mother, father,
upon receipt of Enrollment Form and payment. grandparents, grandchild, step-brother, step-sister, step-parents,
parents-in-law, brother-in-law, sister-in-law, aunt, uncle, niece,
DESCRIPTIONS OF COVERAGE nephew, legal guardian, or legal ward.
“Sickness” means an illness or disease which requires treatment by
Travel Insurance Protection a Physician.
Trip Cancellation & Interruption: We will pay this benefit up to the “Terrorist Incident” means an act of violence, other than civil
Maximum Benefit shown on the Schedule of Benefits if a trip is disorder or riot (that is not an act of war, declared or undeclared)
canceled, or interrupted due to any of the following unforeseen that results in loss of life or major damage to property, by any
circumstances: person acting on behalf of or in connection with any organization
• Sickness, injury, or death of an Insured, Traveling Companion, or which is generally recognized as having the intent to overthrow or
Immediate Family Member. Cancellation due to an injury or influence the control of any government.
Sickness of an Immediate Family Member must be because the “Traveling Companion” means a person or persons with whom you
condition is life-threatening, or because the Immediate Family have coordinated Travel Arrangements and intend to travel with
Member requires the Insured’s care; during the Trip. A group or tour leader is not considered a Traveling
• Financial Default of airline, cruise line, or tour operator resulting Companion, unless you are sharing room accommodations with the
in the complete cessation of services. Excluded is the organization group or tour leader.
from which you purchased your trip or this coverage. This coverage Travel Delay: We will reimburse up to $150 a day to the Maximum
applies only if: (1) you purchased this policy within 15 days of initial shown on the Schedule of Benefits for Reasonable, Additional
trip payment, and (2) the financial default occurs more than 14 days Expenses if the Insured’s trip is delayed for more than 12 hours.
after your coverage effective date; Missed Connection: We will reimburse this benefit up to the Maximum
• Inclement Weather causing cancellation or interruption of travel; shown on the Schedule of Benefits if Inclement Weather or Common
• Strike resulting in the complete cessation of travel services; Carrier causes cancellation or a delay of all regularly scheduled
• Your principal residence or destination being made uninhabitable airline flights for three to less than twelve hours to your point of
by fire, flood, vandalism, burglary, or natural disaster; departure. You can collect up to $250 for additional transportation
• You or a Traveling Companion being subpoenaed, required to costs to join the Trip (must be same class of original tickets
serve on a jury, hijacked, or quarantined; purchased). Reasonable accommodations and meals (up to $100
• A Terrorist Incident in a City listed on your itinerary within 30 days per day) as long as the expense is supported by a proof of purchase
of the Insured’s scheduled arrival. “City” means an incorporated and is not reimbursable by another source, and/or the non-
municipality having defined borders and does not include the high refundable, unused portion of the prepaid expenses. Common Carrier
seas, uninhabited areas, or airspace; must certify the delay of the regularly scheduled airline flight.
• Your being called into active military service or having leave
revoked or being reassigned. Baggage Insurance Protection
Trip Interruption – Return Air Only: We will reimburse the additional Baggage & Personal Effects Loss: Reimburses you for lost, stolen, or
transportation expenses incurred by the Insured to the Return damaged baggage while on your trip. This coverage is in excess of
Destination. However, the benefit payable above will not exceed any other coverage or indemnity, subject to the Maximum shown in
the cost of economy airfare (or first class if the Insured’s original the Schedule. Maximum of $4,000 per traveling group.
tickets were first class) by the most direct route, less any refunds Baggage Delay: Reimburses you for the purchase of covered essential
paid or payable. items when your luggage is delayed more than 24 hours, subject to
“Domestic Partner” means an opposite or a same-sex partner who is the Maximum shown in the Schedule.
at least 18 years of age and has met all of the following requirements
for at least 6 months: (1) resides with the Insured; (2) shares Emergency Medical
financial assets and obligations with the Insured; the Insurer may
Medical Expense: Pays covered Reasonable and Customary medical
require proof of the Domestic Partner relationship in the form of a
expenses incurred due to Sickness or Injuries that occur while
signed and completed Affidavit of Domestic Partnership.
traveling, subject to the Maximum shown in the Schedule.
“Financial Default” means either (i) the complete suspension of
Emergency Medical Transportation: Pays for transportation to the
operations due to financial circumstances, whether or not a
nearest adequate medical facility and includes airfare for your return
bankruptcy petition is filed; or (ii) a partial suspension of the
trip home due to a covered Injury or Sickness occurring during the
operations following a filing of a bankruptcy petition.
trip, subject to the Maximum shown in the Schedule.
page 7 page 8
Additional Coverages traveling expressly for the purpose of obtaining medical treatment;
(n) elective or non-emergency treatment or surgery, except for any
Flight Guard®: Coverage for accidents that occur when traveling on a necessary treatment or surgery due to covered injury;
regularly scheduled flight or charter, subject to the Maximum (o) Experimental or Investigative treatment or procedures; or
shown in the Schedule. (p) an injury or Sickness which occurs at a time when this
Renter’s Collision Coverage: Primary coverage, subject to a $250 coverage is not in effect.
deductible. Covers collision damage to a rental car for which the car ADDITIONAL EXCLUSIONS FOR
rental contract holds the Insured responsible. TRIP CANCELLATION & INTERRUPTION:
Umbrella Package: Valuable additions to increase your coverage.
Your medical and emergency evacuation benefits will double. Your In addition to the General Exclusions, the Insurer will not pay for
medical benefit will be upgraded to primary coverage. For losses due to:
Emergency Evacuation, we will coordinate the appropriate medical (1) carrier-caused delays, including an announced, organized,
transportation to bring you home, or if medically necessary, to the sanctioned labor union strike that affects public transportation,
nearest adequate medical facility. Available globally, anytime you unless the Insured’s coverage effective date is prior to when the
are more than 100 miles from home. You will also receive detailed strike is foreseeable. A strike is foreseeable on the date labor
pre-trip travel advice. (This is not an insured benefit. Rather, it is a union members vote to approve a strike;
service provided by Travel Guard and its member companies.) (2) travel arrangements canceled or changed by an airline, cruise
line, or tour operator, unless the cancellation is the result of
inclement weather or Financial Default as defined;
GENERAL EXCLUSIONS (3) changes in plans by the Insured, an Immediate Family Member,
These exclusions apply to all benefits. In addition to any or Traveling Companion for any reason;
exclusions which apply to a particular benefit, the policy does not (4) financial circumstances of the Insured, an Immediate Family
cover loss caused by: Member, or a Traveling Companion;
(a) intentionally self-inflicted injury or any attempt at an (5) any business or contractual obligations of the Insured, an
intentionally self-inflicted injury, suicide, or attempted Immediate Family Member, or a Traveling Companion;
suicide by the Insured, Immediate Family Member, Traveling (6) Default by the person, agency, or tour operator from whom the
Companion or Business Partner (while sane, in Colorado and Insured bought his/her coverage and purchased his/her travel
Missouri); arrangements, unless due to Financial Default as listed under
(b) pregnancy or childbirth, or elective abortion, other than the the Covered Reasons;
Complications of Pregnancy; (7) any government regulation or prohibition;
(c) participation in professional athletic events, motor sport, or (8) an event or circumstance which occurs prior to the Insured’s
motor racing, including training or practice for the same; effective date of coverage;
(d) mountain climbing; (9) failure of any tour operator, Common Carrier, person, or agency
(e) war or act of war, whether declared or not, civil disturbance, to provide the bargained-for travel arrangements.
riot, or insurrection;
(f) operating or learning to operate any aircraft, as student, pilot, ADDITIONAL EXCLUSIONS FOR
or crew; BAGGAGE & PERSONAL EFFECTS:
(g) air travel on any air-supported device, other than a regularly Property Not Covered: In addition to the General Exclusions, the
scheduled airline or air charter company; Insurer will not pay for damage to or loss of:
(h) loss or damage caused by detention, confiscation, or (a) Animals;
destruction by customs; (b) Bicycles (except when checked with a Common Carrier);
(i) any unlawful acts, committed by the Insured, Immediate (c) Motor vehicles and other conveyances;
Family Member, or a Traveling Companion, whether insured (d) Artificial limbs; false teeth; any type of eyeglasses,
or not; sunglasses, or contact lenses; hearing aids;
(j) mental, psychological, or nervous disorders, including, but (e) Tickets, keys, money, notes, securities, accounts, bills,
not limited to, anxiety, depression, neurosis, or psychosis; currency, deeds, food stamps or other evidences of debt,
(k) if the Insured’s tickets do not contain specific travel dates credit cards, and other travel documents (except passports
(open tickets); and visas);
(l) alcohol or substance abuse or treatment for same; (f) Money, stamps, stocks and bonds, postal or money orders;
(m) medical treatment during or arising from a Trip undertaken (g) Property shipped as freight, or shipped prior to the Trip
for the purpose or intent of securing medical treatment or departure date; or
page 9 page 10
Special Limitation: The Insurer will not pay more than $500 for the through the taking of prescription drugs or medication and remains
first item and thereafter, no more than $250 for each additional item. controlled throughout the 180-day period. A Sickness has manifested
The Insurer will not pay more than $500 aggregate on all losses for itself when medical care, treatment, or diagnosis has been given.
jewelry, watches, furs, cameras and camera equipment, camcorders, The Insurer will waive this exclusion if you meet the following
sporting equipment, computers, and other electronic devices. conditions:
Items over $150 should be accompanied by original receipts. If 1. You purchase the plan within 15 days of making your initial trip
receipts are not provided, benefits may be reduced. payment;
Additional Exclusions: 2. The amount of Trip Cancellation coverage purchased at that time
In addition to the General Exclusions, the Insurer will not pay this equals the full cost of all non-refundable trip arrangements; and
benefit for loss due to: 3. You must be medically able to travel when you pay your
(a) Defective materials or craftsmanship; premium.
(b) Normal wear and tear; “Initial Trip Payment” means the date the first deposit is made to
(c) Deterioration; or your travel agent toward the cost of your trip.
(d) Rodents, animals, or insects.
California Residents: This plan contains disability insurance
ADDITIONAL EXCLUSIONS FOR benefits or health insurance benefits, or both, that only apply
EMERGENCY MEDICAL TRANSPORTATION: during the covered trip. You may have coverage from other sources
In addition to the General Exclusions, the Insurer may not pay for that already provides you with these benefits. You should review
all services arranged without its prior consent or approval. Timely your existing policies. If you have any questions about your current
notification by the Insured to the Insurer’s designated provider is coverage, call your insurer or health plan.
required. The Company reserves the right to determine the Florida Residents: The benefits of the Policy providing your coverage
benefits payable including any reductions, if it is reasonably are governed primarily by the law of a state other than Florida.
possible to contact the Insurer’s designated provider in advance.
North Carolina Residents: In North Carolina, insurance is
ADDITIONAL EXCLUSIONS FOR
underwritten by National Union Fire Insurance Company of
RENTER’S COLLISION INSURANCE:
In addition to the General Exclusions, coverage is not provided for
loss due to: (a) any loss which occurs if the Insured or his/her Texas Residents: This policy may provide a duplication of coverage
Traveling Companion is in violation of the rental agreement; (b) already provided by your personal auto insurance, homeowner’s,
rentals of trucks, campers, trailers, off-road vehicles, motor bikes, personal liability policy, or other sources of coverage.
motorcycles, recreational vehicles, or exotic vehicles; (c) any
obligation the Insured or his or her Traveling Companion assumes Underwritten by the American Home Assurance Company, a
under any agreement except insurance collision deductible; (d) member of the AIG CompaniesSM, with its principal place of
failure to report the loss to the proper local authorities and the rental business at 70 Pine Street, New York, New York 10270. It is
car company; (e) damage to any other vehicle, structure, or person as currently authorized to transact business in all states and the
a result of a covered loss; (f) driving under the influence of alcohol; District of Columbia. NAIC No. 19380.
(g) being under the influence of drugs or intoxicants, unless
prescribed by a physician; (h) Injury sustained while committing or This is only a brief description of the insurance coverage(s) available
attempting to commit a crime. under policy series T30253AHAC. The Policy contains reductions,
PRE-EXISTING MEDICAL CONDITIONS EXCLUSION: limitations, exclusions, and termination provisions. Full details of
the coverage are contained in the Policy. If there are any conflicts
This exclusion applies to ALL Coverages. It applies to you and all
between this document and the Policy, the Policy shall govern.
Immediate Family Members and Traveling Companions, whether or
Coverage may not be available in all states.
not they are traveling with you. Please read it carefully.
The Insurer will not pay for loss or expense incurred as the result of
injury or Sickness of an Insured or Immediate Family Member which
manifested itself, worsened, became acute, or had symptoms, which
would prompt a reasonable person to seek diagnosis, care, or
treatment, or request treatment by a physician or treatment had been
recommended during the 180 days immediately preceding the
Insured’s coverage effective date, unless the condition is controlled
page 11 page 12