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 canceled. 
 

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 can create 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 immediate information 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	Tour Cost to a maximum of: $20,000
Trip Delay	$500
Medical Expense	$10,000
Medical Evacuation / Repatriation	$50,000
Lost Baggage / Personal Effects	$1000
Baggage Delay	$200
24-Hour AD&D	$10,000
Travel Assistance Services	Included
Optional Flight Accident per Trip	$300,000 or $500,000 coverage

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:

1. 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.
2. Strike that causes complete cessation of services of your common carrier for at least 48 consecutive hours.
3. Weather that causes complete cessation of services of your common carrier for at least 48 consecutive hours. 
4. 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.
5. Terrorism in a country, which is part of your scheduled trip, that causes the United States Department of State to issue a travel warning that you should not travel within that country for a period of time, which covers your scheduled trip.
6. 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).
7. Primary residence of you or your traveling companion is rendered uninhabitable due to unforeseen circumstances.
8. Burglary of you or your traveling companion's primary residence within 10 days of departure or during your trip.
9. Felonious assault of you or your traveling companion within 10 days of departure or during your trip.
10. You or your traveling companion are called to emergency military duty for a national disaster other than war.
11. Traffic accident directly involving either you or your traveling companion, substantiated by a police report, while en route to a scheduled departure point.
12. 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. 

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:

1. Any unused non-refundable prepaid expenses for travel arrangements;
2. One-way economy fare to return to your original destination or rejoin your trip less the value of the unused travel ticket.
3. 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.
4. Single supplement upgrade - you will receive benefits when your traveling companion cancels or interrupts a trip for a specified reason and you do not. 

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:

1. Delay of common carrier
2. A traffic accident in which you were not directly involved
3. Inclement weather
4. Quarantine, hijacking or strike
5. Lost or stolen passports, travel documents or money
6. Natural disaster, terrorism or riot 

Benefits include expenses 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. Expenses will be paid for a period of 52 weeks from the date of loss. 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 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).

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); or 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. 

Benefits under this plan are provided by the American Travel Services Trust. The Trust is insured by TIG Insurance Company.  In Oregon, Kansas, New York and South Carolina the benefits of this plan are provided by a policy insured by TIG Insurance Company.

Notice to residents of Florida: The benefits of this plan are provided by the American Consumer Insurance Trust. The Trust is insured by TIG Premier Insurance Company and are governed by the law of a state other than 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.

PROGRAM COSTS

Rates Effective July 1, 2002
 

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 long.
	0 to 55	55 to 70	71 to 80	80 and over
$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 us for the rate.
 

ENROLLMENT IS EASY                      APPLY ONLINE!

1. 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.
2. If paying by check or money order, make payable to: "SRI" and enclose it together with completed Application.
3. If paying by credit card, complete the Application and mail or fax to The Insurance Exchange. Be sure to sign the Method of Payment section (for all payment methods).
4. You may fax if paying by credit card only. Originals are not required if application is faxed with credit card payment.

Return the Application with your payment to: The Insurance Exchange 115 Hulls Hwy Southport, CT  06890 Fax: 661-752-7420 (credit card orders) Phone: 800-385-8550 or 203-254-4490

July 1, 2002                                   CLICK HERE TO PRINT                         Producer #  1659  Kim Michaels

Protection Plan may be purchased if you are a resident of the United States or if you purchase this plan within the United States.

Application Information
(First Name - Middle Name - Last Name)
 

Applicant	Date of Birth (MM/DD/YYYY)
Primary:
Spouse:
Dependent Child:
Dependent Child:

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:
City / State / Zip:
Phone: (      )	Fax: (      )
Beneficiary (For AD&D and optional Flight Accident Coverage):

Rate Calculation
Plan must be purchased for the FULL cost of the trip. See rates.
 

	Trip Cost	Plan Cost (from chart)
Primary	$	$
Spouse	$	$
Dependent Child	$	$
Dependent Child	$	$

For Trips of 31 - 90 Days. Include departure & return dates in calculation:
 

$3

x

# of Days  Over 30

x

Total # of  Travelers

=

$

Optional Flight Coverage (Maximum $500,000 / person):
 

$300,000 Protection for $11	x	Total # of  Travelers	=	$
$500,000 Protection for $18	x	Total # of  Travelers	=	$

 

Non-Refundable Processing Fee:	=	$ 5.00
Total Amount Due:	=	$ And authorized  as payment below

Method of Payment
 

[   ] Check / Money Order Payable to SRI [   ] Visa    [   ] MasterCard    [   ] Discover/Novus    [   ]Diners Club Signature is required below for all methods of payment.
CC Number:
Expiration Date (MM/YY):	Daytime Phone:
Name on Card:
Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an Insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Signature: Mandatory for all  payment options.	Date:

Plan costs are non-refundable after 10-day review period.

In Florida, Florida Resident - Agent No. A269211

Copyright 2002 by Specialty Risk International, Inc.