Order Form

Round Trip Plan

Underwritten for Cook & Company d/b/a TravelCoverage.com by United States Fire Insurance Co., Eatontown, NJ

To purchase this plan please provide the following information and click the ‘Next’ button to continue to the next page where you will be provided your real-time quote. Click here to view the details of this plan (benefits, pricing, and description of coverage) and it’s underwriter.

Eligibility: All Travelers must be at least 18 years of age and a Resident of the US.

Trip Overview

All Travelers meet eligibility requirements listed above?(Required)

YES

Selected Plan(Required)

$1,000,000 AD&D

$500,000 AD&D

$250,000 AD&D

Trip Departure Date(Required)

Trip Return Date(Required)

Destination

Originating Airline

Originating Flight#

Primary Traveler Information

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Additional Travelers

Name	Actions

There are no Additional Travelers.

Plan Cost

Price: $0.00

Additional Traveler Cost

Price: $0.00

Review Coverage & Policy Information

Plan:	{Selected Plan:19}
Travel Dates:	{Trip Departure Date:7} to {Trip Return Date:8}
Primary Traveler:	{Name (First):14.3} {Name (Last):14.6}
Additional Travelers	{Additional Travelers:21}
Contact Address:	{Address (Street Address):15.1} {Address (Address Line 2):15.2} {Address (City):15.3}, {Address (State / Province):15.4} {Address (ZIP / Postal Code):15.5} {Address (Country):15.6}
Phone:	{Phone:16}
Email:	{Email:17}

Policy Quote

Beneficiary Information

Beneficiary Name

Beneficiary Relationship

(default will be insured's estate)

Payment Detail

Credit Card

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

I represent the above information is true. If any information is false or omitted the company has the right to render the coverage null and void. I understand that insurance is automatically null and void if the payment is returned uncollectable or unapproved for any reason. I hereby subscribe to the AIG Group Insurance Trust and enroll in the group coverage for which I am eligible under the Group Insurance Contract issued by United States Fire Insurance Co. I acknowledge that I have read, understand, and agree to the terms and conditions of the insurance as detailed in the Description of Coverage. Click the 'PURCHASE POLICY' button if you accept the above and the amount will be charged to your credit card.