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Terms & Conditions
PLEASE READ BEFORE SUBMITTING
Residents of Pennsylvania
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
Residents of New York
Any person who knowingly and with the intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
Resident of all other states
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Any person who knowingly and with intent defrauds any insurance company is subject to criminal and civil penalties. I represent that the above information is true and the dates reflect my intent to start and end my trip. The coverage goes into effect after the premium is paid on the effective date on the confirmation or at 12:01am on the day after the postmark, telephone purchase, fax transmission date, or online purchase confirmation date. The Insurer reserves the right to reject any enrollment. I understand there is no coverage for loss due to pre-existing medical conditions, unless this insurance is purchased within the required time frame to waive this exclusion. I understand that if payment is returned unpayable for any reason, the coverage becomes null and void. I also understand that any changes to this enrollment form do not change the coverage of the policy.