Fillable Outbound-Inbound Travel Application36-10804

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Outbound-Inbound Travel Application36-10804

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GROUP INBOUND / OUTBOUND TRAVEL ACCIDENT & SICKNESS
INSURANCE REQUEST FOR COVERAGE
Name of Organization:
Street Address:
City:
State:
Zip:
1.
Has this organization had prior travel accident & sickness coverage?
Yes
No
2.
a.
Start Date of Travel:
End Date of Travel:
b.
Destination(s):
c.
Purpose of Trip:
d.
Number of Travelers:
3.
a.
Start Date of Travel:
End Date of Travel:
b.
Destination(s):
c.
Purpose of Trip:
d.
Number of Travelers:
4.
Trip #3:
a.
Start Date of Travel:
End Date of Travel:
b.
Destination(s):
c.
Purpose of Trip:
d.
Number of Travelers:
In order to bind coverage, the carrier requires a signed application, which will be attached to the proposal we
issue, and a name list of travelers. We handle this line agency bill.
ACKNOWLEDGEMENTS AND SIGNATURES
a.
company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of
b.
statements and answers in this application are true and complete. I understand and agree that (a) this application
will form part of any policy issued, (b) no information given to or acquired by any representative of Philadelphia
Indemnity Insurance Company will bind it, unless it is in writing on this application, (c) no waiver or modification will
bind the Company unless it is in writing and is signed by an executive office of Philadelphia Indemnity Insurance
Signed:_________________________________________
Title:
Date:
Agent Name:
Agency:
Address:
City:
State:
Zip:
Email:
Phone:
Fax:
Please return form to:
The Allen J. Flood Companies, 2 Madison Avenue, Larchmont, NY 10538
info@ajfusa.com ● Phone: 1-800-734-9326
Outbound-Inbound Travel Application
Page 1 of 1
© 2015 Philadelphia Consolidated Holding Corp.
09/2015
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Outbound-Inbound Travel Application36-10804

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Completed 2 July 2020

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