Group Trip Insurance

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Group Name*
Contact Person's Name*
Contact Person's Phone*
Contact Person's Email*
Departure Date
MM slash DD slash YYYY
Return Date
MM slash DD slash YYYY
Initial Trip Payment Date
MM slash DD slash YYYY
Final Trip Payment Date
MM slash DD slash YYYY
Name of Airline, Tour Operator/Cruise Line
Citizenship of Travelers (i.e. US or non-US)
- US
- Non US
Current Location of Travelers (i.e. in US or outside-US)
- US
- Non US
Confirm that you need medical coverage for sicknesses & accidents (i.e. Yes or No)
- Yes
- No
Confirm that you seek coverage for trip cancellation costs; this will increase your insurance premium
- Yes
- No

Please enter the trip cost and number of travelers in the appropriate boxes:

Trip Cost	0 - 34 years	35 - 59 years	60 and above years