Group Travel Proposal Request Form


First Name: City
Last Name: State
Company: Zip
Street Address 1: Phone#:
Street Address 2: Fax#:
    E-Mail:

Group Name:

State:
Zip Code:     
Nature of Business :    

Does the firm now carry Travel Insurance?

If Yes, please provide Name of Present Carrier and Loss Experience
Total number of employees:
Are Drivers and Deliverymen to be covered?
What is the maximum number of employees traveling together?
How many automobiles are used on company business?
Are there any company owned or leased Aircraft?
If there is any Aircraft exposure (other than scheduled airline) please explain.
 
Classes of Employees to be Covered:
Describe by Title, Position, Name, Salary or Blanket Coverage.
Indicate Benefit Amount Desired for each class.		  
Indicate Benefits desired:
Accidental Death & Dismemberment
Permanent Total Disability
Accident Medical Expense
Accident Total Disability Income

Number who travel on business over 75 days a year?

Total number of days away on business by
those who travel less than 75 days a year?
Please add any suggestions or comments which might be helpful.
Do you wish your proposal sent to you by:  Mail Fax Phone

                                        
 
 
 
 
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