PRINT OUT THIS FORM, FILL IT IN AND FAX IT TOOL FREE AT: 

1-860-528-8006

You must purchase Worldwide Trip Protector within 7 days of your initial trip deposit to qualify for the 7 day ADVANTAGE (see brochure for details)

PART 1 - NAME, ADDRESS AND TRIP INFORMATION
1. Name (First, MI, Last):	2. Street Address (P.O. Box):	3. City, State, Zip:

4. Departure Date (mm/dd/yy): //

5. Departure Hour: AM PM

6. Return Date (mm/dd/yy): //

7. Date of Birth (mm/dd/yy): //

8. Initial Trip Deposit Date (mm/dd/yy): //

9. Daytime Telephone: () -

10. Evening Telephone: () -

11. Term: # of Days of Travel:

12. Name of Cruise Line or Operator:

13. Check all that apply: Tour    Cruise Land    Air

14. Traveling Companions: List anyone protected under another Travel Insured International, Inc. protection plan traveling with you (if applicable). Attach additional page, if necessary. a.    b.    c.

15. Beneficiary:

16. Destination:

PART 2 - PAYMENT CALCULATION
CHOOSE THE PLAN YOU WISH TO PURCHASE FOR ALL TRAVELERS: COMPREHENSIVE PLAN      POST DEPARTURE PLAN   NAME DATE OF BIRTH (MM/DD/YYYY) FILL-IN TRIP COST OR LENGTH OF TRIP SELECT & FILL-IN THE PLAN RATE PURCHASER: // #2: // #3: // #4: // #5: // CALCULATE ADDITIONAL COST FOR TRIPS OVER 30 DAYS: # OF DAYS X # OF TRAVELERS X $3.00 = SUBTOTAL FOR THIS SECTION:

THE PURCHASE OF THE OPTIONAL FLIGHT ACCIDENT PLAN MUST APPLY TO ALL TRAVELERS. $100,000 - $5/PERSON $250,000 - $11/PERSON PLAN RATE X # OF TRAVELERS = SUBTOTAL BOTH SECTIONS    NON-REFUNDABLE ADMINISTRATION FEE:   $5.00 TOTAL:

PART 3 - HOW TO PAY
CHECK OR MONEY ORDER ENCLOSED (MAKE PAYABLE TO: TRAVEL INSURED INTERNATIONAL, INC.) MasterCard     Visa     Expiration: / NAME ON CREDIT CARD:        NUMBER ON CREDIT CARD: SIGNATURE:________________________________________________________________________ SIGNATURE REQUIRED FOR ALL PAYMENT OPTIONS

Name of Travel Agency Tll Agency Number If we encounter problems with this application, whom should we contact? Agency   Plan Holder