COVER-PRO
SM
APPLICATION
TRAVEL AGENT SUPPLEMENT
1. Full name of the Applicant Firm:
2. Please provide a breakdown of the most recent twelve (12
) months gross ann
ual revenue:
Description Percentage of Operations
Individual Bookings %
Groups %
Corporate %
Foreign %
Domestic Travel %
Cruises %
3. Does the Applicant acts as a Travel Agent
Tour Operator Tour Operator / Guide?
4. Is the Applicant involved in marketing and / or sellin
g any of the following types of tours?
Commercial travel:
Yes No
Foreign tours: Yes No
Student / Adventure: Yes No
Cruise lines operations:
Yes
No
5. Conferen
ce in whi
ch the Applicant holds ap
pointments. Check all that apply:
ARC TPPC IATAN ASTA AMTRAK IATA CLIA
6. Do any of the Applicant’s agents hold the designation of Certified T
ravel Counselor? Yes No
7. Has the Applicant ever defaulted or have any of the Own
ers, Partners or Officers of the Applicant ever b
een
associated with any agency which has defaulted to a carrier, conference, or supplier? Yes No
8. Does the Applicant arrange adventure trips that involve high-risk activities? Yes No
9. Does the Applicant run a specialty travel agen
cy? (i.
e.: crui
se
s, honeymoo
ns,
adventure trip
s) Yes No
10. Does the Applicant sell sports or event tickets in
conjunction with travel?
Yes No
11. Do any of the Applicant’s employees accompany c
lients on trips?
Yes No
12. How often does the Applicant consult the U.S. State Depa
rtment’s advisories rega
rding which foreign countries
are deemed safe for travel?
13. Does your agency offer travel insurance? Yes No If yes, through which companies?
PI-PLSP-TASUPP-FL 08/10
Page 1 of 2
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PI-PLSP-TASUPP-FL 08/10 Page 2 of 2
AD
DITIONAL INFORMATION
This section may be used to provide additional information to
any
question on this application. Please
identify the question number to which you are referring.
NOTICE TO FLORIDA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTE
NT TO INJU
RE,
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.
I understand that the information submitted herein becomes a part of my Philadelphia Insurance
Companie
s Cov
e
r-Pro
sm
application and is subject to the same conditions as stated on the application.
Name (Please Print) Title (Must be Principal, Partner or
Officer)
__________________________________________
Signature Date
Agency Name: Agency Number:
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