Purchase Insurance Form

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Travel Information




When selecting more then one country hold down the control key before clicking the mouse (command key on MacOS)
Can't see your destination country in the list?
Your country is not on the list since it is considered to be deemed a war risk territory which requires a different pricing schedule. Please have your insurance broker or representative contact us to secure the appropriate cost for your trip.


Note: The number of coverage days includes the return date.
Accidental Death Benefits will be paid to the first of the following classes:
1) spouse; 2) children; 3) parents; 4) brothers and sisters.
If there are no survivors in any of these classes, benefits will be paid to the Applicant’s estate.

Coverage



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Please read the following before you continue...

I understand that a refund premium (less a $10.00 processing fee) will be considered only if a written request is received by Reueben Warner Associates, Inc., prior to the effective date of coverage. After that date, the premium is considered fully earned and non-refundable. Partial refunds are not available.

Further, I understand my information is protected by privacy laws and will be released only in accordance with these laws.

WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the Applicant.

For Florida Residents – Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

For Kentucky Residents – Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

For New York Residents – 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 materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed $5,000 and the state value of the claim for each such violation.

For Oklahoma Residents – Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

For Oregon Residents – Any person with the intent to knowingly defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto that is related to the acceptance of the risk by the insurer, may subject to prosecution.

I certify that I have read the complete plan description, and understand the terms and conditions of coverage that apply to me including any limitations or exclusions that may apply to my coverage.

I have read the plan description and understand the terms and conditions including the limitations and exclusions.

Credit Card Information