Insurance

Telephone: 615-566-9085 Email: travel@rowlandent.com Fax: 615-250-0530

Credit Card Authorization Form

FOR BELOW: PLEASE NOTE FOR TRIPS WITHIN THE U.S., A U.S. DRIVER’S LICENSE NUMBER WILL SUFFICE INSTEAD OF A PASSPORT

Contact Name

Contact Phone

Type of Insurance Plan

Comments or Special Requests

Passenger 1 Name as on passport

Passenger 1 Date-of-Birth

Passenger 1 Passport #

Passenger 1 Trip Cost ($)

Passenger 1 Dates of Travel (mmddyy to mmddyy)

Passenger 2 Name as on passport

Passenger 2 Date of Birth

Passenger 2 Passport #

Passenger 2 Trip Cost ($)

Passenger 2 Dates of Travel (mmddyy to mmddyy)

Passenger 3 Name as on passport

Passenger 3 Date of Birth

Passenger 3 Passport #

Passenger 3 Trip Cost ($)

Passenger 3 Dates of Travel (mmddyy to mmddyy)

Passenger 4 Name as on passport

Passenger 4 Date-of-Birth

Passenger 4 Passport #

Passenger 4 Trip Cost ($)

Passenger 4 Dates of Travel (mmddyy to mmddyy)

Rowland Enterprises is a proud licensed Partner Agent with travel insurance provider Access America and emergency medical evacuation provider MedJet Assist. Click on the vendor links below to review policies/memberships. To purchase a policy/membership, U.S. and Canadian residents can complete and submit the requested information below and the Credit Card information for payment. You may call or fax your order and payment as well. Safeguard your travel investment today!

Travel Insurance & Medical Evacuation