PROTECT YOUR TICKETS, YOUR LUGGAGE, AND
YOUR HEALTH, WORLDWIDE.
 | TRIP CANCELLATION
|
 | INTERRUPTION / DELAY
|
 | EMERGENCY MEDICAL AND DENTAL
|
 | MEDICAL TRANSPORTATION
|
 | LOST OR STOLEN BAGGAGE
|
 | MISSED CONNECTION |
WHY ROUNDTRIP?
So you'll be prepared. Who knows what could happen during a
trip abroad - or before you even depart. Not only does RoundTrip
help ensure you're prepared in the event of an accident,
sickness or loss when traveling, it can even help if something
causes your trip to be cancelled.
While we've optimized RoundTrip's medical coverage for most
travelers, you may determine you need greater coverage or
specific benefits. Consider Liaison® International or other
plans from SRI for up to $5,000,000 of international medical
limits. We have a plan that's right for you.
Protection Plan Outline
This brochure describes the highlights of our protection plan. Plan
details and ID Card will be mailed to you once you have
purchased benefits or obtained immediately when using the online
system. These details provide complete information regarding the
benefits, exclusions and limits of the protection plan. Please
read it carefully. Note: Certain terms are defined in the
Evidence of Benefits that will be mailed to you with your
confirmation.
SCHEDULE OF BENEFITS
|
Benefit |
Per Person Limit |
|
Trip Cancellation |
Tour Cost to a maximum of: $20,000 |
|
Trip Interruption |
150% of Tour Cost Maximum |
|
Trip Delay / Missed Connection |
$500 |
|
Medical Expense |
$50,000 |
|
Medical Evacuation / Repatriation |
$250,000 |
|
Lost Baggage / Personal Effects |
$1,000 |
|
Baggage Delay |
$200 |
|
24-Hour AD&D |
$10,000 |
|
Common Carrier AD&D |
$25,000 |
|
Travel Assistance Services |
Included |
|
Optional Flight Accident per Trip |
$100,000 or $300,000 |
DESCRIPTION OF BENEFITS
Trip Cancellation / Interruption
Trip Cancellation:
You have benefits in the amount purchased for unused non-refundable
prepaid expenses for travel arrangements, whenever you are
prevented from taking a trip for any of the following reasons
that occur after the effective date* of your protection plan:
- Specified sickness, injury or death of you, your
traveling companion, business partner or family member of
either you or your traveling companion that results in
medically imposed restrictions as certified by a legally
qualified physician at the time of loss, preventing your
continued participation in the trip.
- If you purchase RoundTrip within ten (10) days of your
initial trip payment and for the full non-refundable cost of
your trip, you will be eligible for benefits up to a maximum
limit of $20,000 or the benefit amount protected, whichever
is less, due to bankruptcy or default of an airline, cruise
line, or tour operator (other than the travel agent or
travel supplier that solicited this protection plan and from
whom you purchased your travel arrangements) which stops
service more than fourteen (14) days following your
protection plan effective date. Your scheduled departure
date must be no more than fifteen (15) months beyond the
effective date of your protection plan. Benefits will be
paid due to bankruptcy or default of an airline only if no
alternate transportation is available. If alternate
transportation is available, benefits will be limited to the
change fee charged to allow you to transfer to another
airline in order to get to your intended destination. The
bankruptcy or default benefit is excess and secondary to all
other forms of indemnity. For the post-departure plan you
must protect the full length of your trip. Coverage does not
apply if the petition for bankruptcy was filed prior to the
effective date of your protection plan.
- Strike that causes complete cessation of services of
your common carrier for at least 48 consecutive hours.
- Weather that causes complete cessation of services of
your common carrier for at least 48 consecutive hours.
- Employer termination or layoff affecting you or a person
sharing the same room. Employment must have been with the
same employer for at least three continuous years.
- Terrorism. The terrorist incident must occur in a city
listed on your itinerary within 30 days prior to your
Scheduled Departure Date. This same city must not have
experienced a terrorist incident within 90 days prior to the
terrorist incident, which is causing your cancellation.
Benefits are not provided if your travel supplier offers a
substitute itinerary.
- Hijack, quarantine, jury duty or court ordered
appearance as a witness in a legal action in which you or
your traveling companion are not a party (except law
enforcement officers).
- Primary residence of you or your traveling companion is
rendered uninhabitable due to unforeseen circumstances.
- Burglary of you or your traveling companion's primary
residence within 10 days of departure or during your trip.
- Felonious assault of you or your traveling companion
within 10 days of departure or during your trip.
- You or your traveling companion are called to emergency
military duty for a national disaster other than war.
- Traffic accident directly involving either you or your
traveling companion, substantiated by a police report, while
en route to a scheduled departure point.
- If your travel supplier cancels your trip, you will
receive up to $75 for the reissue fee charged by the airline
for your tickets. You must cover the full cost of the trip.
* Effective Date is the date which begins at 12:01 a.m.
following the: 1) postmark date of your enrollment form or 2)
the date you fax or transmit your enrollment via the internet
with the proper payment.
Trip Interruption:
If you are prevented from completing a trip for any of the above
reasons that occur after the effective date of your protection
plan and during your trip, you will receive up to the amount
purchased for:
- Any unused non-refundable prepaid expenses for travel
arrangements.
- One-way economy fare to return to your original
destination or rejoin your trip less the value of the unused
travel ticket.
- Accommodations and transportation expenses for up to
$150/day for 10 additional days when your traveling
companion must remain hospitalized or a specified injury or
sickness not requiring hospitalization prevents you from
continuing travel, causing you to extend your trip with
additional hotel nights due to medically imposed
restrictions as certified by a legally qualified physician.
- Single supplement upgrade - you will receive benefits
when your traveling companion cancels or interrupts a trip
for a specified reason and you do not.
Trip Delay / Missed Connection:
Benefits include additional transportation cost to join the covered
trip or return home and/or for unused non-refundable expenses
for your covered trip. Delay must be three hours or more and
certified due to one of the following reasons:
- Delay of common carrier
- A traffic accident in which you were not directly
involved
- Inclement weather
- Quarantine, hijacking or strike
- Lost or stolen passports, travel documents or money
- Natural disaster, terrorism or riot
Medical Expense:
Benefits include expenses incurred during your trip for an accidental
injury or a sickness that manifests itself during your trip, as
long as you receive initial medical treatment within 30 days
after the date of loss. Medical Expense coverage will end upon
return to your home or the return date stated on the application
whichever is sooner. Benefits will include expenses for
emergency dental treatments, up to $750 ($750 sub limit does not
apply in New York) and advance payment to a hospital if needed
to secure your admission.
Medical Evacuation / Repatriation:
You will receive benefits if an injury or sickness first occurs during
your trip, up to the policy limit, for medical evacuation or
medically necessary repatriation to your home or a hospital near
your home for continued treatment when your condition is acute
or life threatening and adequate treatment is not available at a
local hospital. Benefits will also be paid to return your mortal
remains to your home should you die while on your trip (as
described in the Travel Assistance Service Section).
Benefits also include transportation for the return trip home
for your dependent children under age 18 who are accompanying
you and are left unattended if you are confined to a hospital
for more than seven consecutive days. Transportation will be
provided for a person of your choice to visit you if you are
traveling alone and are confined to a hospital for more than
seven consecutive days. Any use of this benefit must be
pre-approved and arranged by the authorized Assistance Company.
Note: Pre-existing condition limitations are waived for Medical
Evacuation / Repatriation.
Lost Baggage & Baggage Delay:
You will receive benefits for lost, stolen or damaged luggage and
personal items, as well as a lost or stolen passport, visa and
credit cards. You also have benefits for checked luggage that is
delayed or misdirected by a common carrier for more than 24
hours from your arrival time at a destination, other than your
residence, during your trip. Benefits are payable on property
not specifically scheduled under other insurance.
Accidental Death & Dismemberment
(AD&D):
You will receive benefits for loss of life or dismemberment due to an
accidental injury while on your trip.
Optional Flight Accident Plan:
These benefits apply to the amount purchased, for accidental death,
dismemberment or loss of sight as a result of an accident while
a passenger on a regularly scheduled air flight, a land or water
conveyance provided by the airline as a substitute for an
aircraft, a common carrier while en route to or from the
airport, or at the airport immediately before boarding or after
disembarking from an aircraft.
Travel Assistance Service
Travel Assistance provides a variety of travel related services.
Services offered include: medical evacuation / repatriation;
repatriation of remains; medical or legal referral; hospital
admission guarantee; emergency cash advance*; translation
service; prescription drug / eyeglass replacement*; passport /
visa information; bail bond*; lost baggage retrieval;
inoculation information. (*Payment reimbursement to the
Assistance Company is your responsibility)
WHEN YOU ARE ELIGIBLE FOR BENEFITS
"Effective Date" is 12:01a.m. following the postmark of your
enrollment form or the date you fax or transmit your enrollment
via the Internet with the proper payment.
 | Trip Cancellation and Assistance Services - your
eligibility begins on your effective date.
|
 | Trip Delay / Missed Connection - in force while you are
en route to and from your covered trip.
|
 | Flight Accident Plan (if chosen) - begins on the
departure date or the date your completed enrollment form
and fees are postmarked, faxed, or transmitted via the
Internet and ends when the trip is completed or after 30
days (unless additional days are purchased), whichever comes
first.
|
 | All Other Coverages (includes Trip Interruption) - you
become eligible for benefits at 12:01 a.m. on your scheduled
departure date or your effective date whichever is later,
and ends at the point and time of return on the scheduled
return date. |
 | Maximum Trip Length under RoundTrip is 30 days (unless
additional days are purchased). |
ELIGIBILITY
RoundTrip may be purchased if you are a resident of the
United States or if you purchase this plan within the United
States.
Dependent Children are children of the Primary Applicant
under 19 years of age.
WHEN BENEFITS DO NOT APPLY
Benefits are not payable for sickness, injuries or losses of you
or your traveling companion:
- resulting from suicide, attempted suicide, or
intentionally self-inflicted injury while sane or insane (in
Missouri, sane only; in New York, neither sane nor insane
apply);
- resulting from an act of declared or undeclared war;
while participating in maneuvers or training exercises of an
armed service;
- while riding, driving or participating in races or speed
or endurance contests;
- while mountaineering (engaged in the sport of scaling
mountains, generally requiring the use of picks, ropes or
other special equipment; in New York, professional
mountaineering);
- while participating as a member of a team in an
organized sporting competition;
- while participating in skydiving, hang gliding, bungee
cord jumping, scuba diving or deep sea diving (in New York,
professional scuba - any sport that requires more than an
"Open Water 1" certification by PADI, NAUI, or other
recognized diving certification organization);
- any Mental and Nervous disorders, unless hospitalized;
- while piloting or learning to pilot or acting as a
member of the crew of any aircraft;
- received as a result or consequence of being intoxicated
or under the influence of any controlled substance unless
administered on the advice of a legally qualified physician;
- to which a contributory cause was the commission of or
attempt to commit a felony or being engaged in an illegal
occupation;
- due to normal childbirth, normal pregnancy (except
complications of pregnancy) or voluntarily induced abortion
(voluntary abortion only in New York);
- for dental treatment (except as coverage is otherwise
specifically provided herein);
- due to a pre-existing condition - note the pre-existing
condition limitation is automatically waived for emergency
medical evacuation and medically necessary repatriation
benefits, and for benefits purchased within 10 days from the
time the initial deposit is paid on your covered trip.
- In California benefits are not payable if during the 60
days prior to your effective date, a legally qualified
physician advised you or your traveling companion not to
travel due to a sickness or injury. No benefits will be paid
for expenses reimbursed or services provided by any other
source.
WHEN "PRE-EXISTING" APPLIES
Pre-existing medical conditions, as defined in the section
below, will apply if you enroll in the protection plan more than
10 days after making your initial trip deposit.
"Pre-existing Condition" means any injury, sickness or condition
(including any condition from which death ensues) of you or your
traveling companion, you and/or your traveling companion's
family member or your business partner which within the sixty
(60) day period prior to the effective date of your trip
cancellation benefits under this protection plan: a) manifested
itself, became acute or exhibited symptoms which would have
caused one to seek diagnosis, care or treatment; b) required
taking prescribed drugs or medicine, unless the condition for
which the prescribed drug or medicine is taken remains
controlled without any change in the required prescription; or
c) required medical treatment or treatment was recommended by a
legally qualified physician.
Note, in California, part "(a)" of the Pre-existing Condition
is not applicable.
CLAIM QUESTIONS & SITUATIONS
Once you have enrolled, you will receive an Evidence of
Benefits and ID Card, which will describe all aspects of the
program, as well as who to contact in case of an emergency or if
a claim should occur. The Assistance Company should be contacted
if you require assistance while on your trip. When purchasing
your trip, be sure to keep all documentation. This information
will be required in order to process any claim.
Products underwritten by Nationwide Mutual Insurance Company,
Nationwide Life Insurance Company and Nationwide Mutual Fire
Insurance Company.
Notice to residents of Florida: Your homeowners policy, if
any, may provide coverage for loss of personal effects provided
by the baggage and personal effects coverage. This insurance is
not required in connection with the purchase of your travel
arrangements.
Notice to residents of California: This plan contains
disability benefits or health benefits, or both, that only apply
during the covered trip. You may have coverage from other
sources that already provides you with these benefits. You
should review your existing policies. If you have any questions
about your current coverage, call your insurer or health plan.
Note, in California the pre-existing condition limitation is
waived for medical expenses.
|
Trip Cost per person |
Plan Rate per person based on age
on date of purchase |
Coverage must be purchased
for the full cost of the trip. |
The rates below are for trips from 1 through 30 days in
length |
| |
0 to 55 |
56 to 70 |
71 to 80 |
over 80 |
| $0 Post departure only** |
$25 |
$35 |
$50 |
$97 |
| $0-$500 |
$33 |
$48 |
$73 |
$122 |
| $501-$1,000 |
$46 |
$75 |
$102 |
$171 |
| $1,001-$1,500 |
$58 |
$94 |
$131 |
$219 |
| $1,501-$2,000 |
$74 |
$120 |
$165 |
$278 |
| $2,001-$2,500 |
$100 |
$150 |
$235 |
$411 |
| $2,501-$3,000 |
$115 |
$185 |
$284 |
$487 |
| $3,001-$3,500 |
$129 |
$219 |
$332 |
$564 |
| $3,501-$4,000 |
$144 |
$261 |
$387 |
$654 |
| $4,001-$4,500 |
$164 |
$302 |
$446 |
$740 |
| $4,501-$5,000 |
$183 |
$344 |
$501 |
$827 |
| $5,001-$5,500 |
$263 |
$425 |
$586 |
$983 |
| $5,501-$6,000 |
$288 |
$465 |
$643 |
$1,077 |
| $6,001-$6,500 |
$313 |
$506 |
$698 |
$1,171 |
| $6,501-$7,000 |
$342 |
$553 |
$765 |
$1,279 |
| $7,001-$8,000 |
$376 |
$607 |
$839 |
$1,404 |
| $8,001-$9,000 |
$424 |
$686 |
$946 |
$1,585 |
| $9,001-$10,000 |
$474 |
$766 |
$1,058 |
$1,772 |
For trips of longer than 30 days, additional cost of $3 per
person per day is required.
For trip cost between $10,001 and $20,000, contact your producer
or SRI for the rate.
Note: This plan may not be available in all states. Please
contact SRI for a list of approved states.
-
Apply Online and receive
your ID card immediately when you finish your application
- Read the entire brochure and complete the Roundtrip
Application in full. Plan cost for the entire package is due
at the time of application. Remember: Benefits must be
purchased for the full cost of the trip.
- If paying by check or money order, make payable to:
"SRI" and enclose it together with completed Application.
- If paying by credit card, complete the Application and
mail or fax to SRI. Be sure to sign the Method of Payment
section (for all payment methods).
|
Return the Application with
your payment to: John K.
Arnold PO Box 300801 Fern Park, Florida
32730-0801
Fax: 407-386-7053 (credit
card orders) Phone: 407-830-0259 Online: www.insurance-network.com
Make checks payable to Specialty Risk or SRI
(You may fax if paying by
credit card only. Originals are not required if application is faxed with
credit card payment.) You can also apply online at http://www.insurance-network.com/usbased/index.htm
|
ROUNDTRIP ENROLLMENT FORM
June 1, 2005
|
 |
Producer # ____John K Arnold 4449_______________________
Protection Plan may be purchased
if you are a resident of the United States or if you
purchase this plan within the United States. |
Applicant Information
(First Name - Middle Name -
Last Name) |
|
Primary Applicant:
_____________________________________________
|
| Birth Date (MM/DD/YYYY):
______ / ______ / ______ |
|
Spouse:
_______________________________________________
|
| Birth Date (MM/DD/YYYY):
______ / ______ / ______ |
Dependent Child:
_____________________________________________
(under 19 years of age)
|
| Birth Date (MM/DD/YYYY):
______ / ______ / ______ |
Dependent Child:
_____________________________________________
(under 19 years of age)
|
| Birth Date (MM/DD/YYYY):
______ / ______ / ______ |
| |
|
Trip Information |
|
Departure Date (MM/DD/YYYY): ______ / ______ /
______ |
|
Return Date (MM/DD/YYYY): ______ / ______ /
______ |
|
Destination:
_____________________________________________ |
Name of Travel Supplier:
________________________________________
(Airline, Tour Operator,
Cruise Line, etc.) |
| |
|
Personal Information |
Your Address:
__________________________________________________
(must be a U.S. address)
|
|
City / State / Zip:
_____________________________________________
|
|
Phone: ( ____ ) _______________ Fax: ( ____
) _______________ |
|
Email Address:
_____________________________________________
|
Beneficiary:
________________________________________________
(For AD&D and optional
Flight Accident Coverage) |
| |
| |
| In Florida, Florida Resident
- Agent No. A269211 |
|
|
|
|
|