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As always, you are welcome
to call
or
e-mail us with your travel insurance requests, or fill out the
appropriate form below to
order immediately.
And importantly, please also download, fill out
and fax us the
Credit Card
Authorization Form
and your Travel Insurance will be processed.
To
Order MEDJET
Insurance, fill out the MEDJET ORDER FORM by scrolling down or clicking
HERE OR
order directly from MEDJET by clicking here:
www.medjetassist.com/rowland.
To
order ACCESS
AMERICA Insurance, fill out the
form immeditely following.
TRAVEL INSURANCE ORDER
FORM FOR ACCESS AMERICA
E-mail address:
Daytime phone
number in case of questions (optional):
ACCESS AMERICA Insurance Plan Ordered
Coverage Ordered
Passenger 1 Name:
Date of
Birth
Passenger 2 Name:
Date of
Birth
Passenger 3 Name:
Date of
Birth
Passenger 4 Name:
Date of
Birth
Departure Date:
Return Date:
Trip Cost Per Person $
(USD)
Total Cost: $ (USD)
State or Province
of Residence:
Ready to Order? Hit SUBMIT and don't
forget to fax the
Credit Card Authorization Form.
TRAVEL INSURANCE ORDER
FORM FOR MEDJET
E-mail address:
Daytime phone
number in case of questions:
Evening phone
number in case of questions:
MEDJET Insurance Plan Ordered
Plan Coverage Type:
Length of Coverage:
Membership Status:
Member Applicant First
Name:
Member Applicant Last
Name:
Member Applicant Full
Home Address, including street, house or apartment number, city, state,
and zip code
Member Applicant Date
of Birth (required by MEDJET):
Member Applicant
Daytime Phone:
Member Applicant
Evening Phone:
Member Applicant
E-mail Address:
Passenger Two First &
Last Name and Date
of Birth (required by MEDJET):
Passenger Three First
& Last Name and Date
of Birth (required by MEDJET):
Passenger Four First &
Last Name and Date
of Birth (required by MEDJET):
Passenger Five First &
Last Name and Date
of Birth (required by MEDJET):
Additional Passengers'
First & Last Name and Date
of Birth (required by MEDJET):
THANK YOU! |