Enrollment Options Meet Your Travel NeedsThe following exclusion applies to the Medical Expense, Trip Cancellation, Trip Interruption,and Trip Delay coverages: We will not pay for loss or expense caused by or incurred resulting from a Pre-ExistingCondition, as defined in the plan, including death that results therefrom. This exclusiondoes not apply to benefits under Medical Evacuation and Repatriation Benefits.The following exclusion applies to the Accidental Death & Dismemberment coverage: We willnot pay for loss caused by or resulting from Sickness of any kind.The following exclusions apply to all coverages: We will not pay for any loss under theplan, caused by, or resulting from: suicide, attempted suicide, or intentionally self-inflictedinjury, while sane or insane (while sane in CO and MO); mental, nervous, or psychologicaldisorders (does not apply to Medical Expense Benefits); being under the influence of drugsor intoxicants, unless prescribed by a physician; normal pregnancy or resulting childbirthor elective abortion; participation as a professional in athletics; riding or driving in anymotor competition; declared or undeclared war, or any act of war; civil disorder (does notapply to Trip Delay); service in the armed forces of any country; operating or learning tooperate any aircraft, as pilot or crew; mountain climbing, bungee cord jumping, skydiving,parachuting, hang gliding, parasailing or travel on any air supported device, other thanon a regularly scheduled airline or air charter company; any criminal acts, committedby you; a loss or damage caused by detention, confiscation or destruction by customs;elective treatment and procedures; medical treatment during or arising from a coveredtrip undertaken for the purpose or intent of securing medical treatment; a loss that resultsfrom an illness, disease, or other condition, event or circumstance which occurs at a timewhen the plan is not in effect for you.Please refer to your Description of Coverage for Baggage/Baggage Delay and Rental CarDamage exclusions.DEFINITIONS: Pre-Existing Condition means an illness, disease, or other conditionduring the 60 day period immediately prior to your effective date for which you or yourTraveling Companion, Domestic Partner, Business Partner or Family Member scheduledor booked to travel with you: 1) received or received a recommendation for a diagnostictest, examination, or medical treatment; or 2) took or received a prescription for drugsor medicine. Item (2) of this definition does not apply to a condition which is treated orcontrolled solely through the taking of prescription drugs or medicine and remains treatedor controlled without any adjustment or change in the required prescription throughout the60 day period before coverage is effective under this Policy.This plan provides insurance coverage for a covered trip. The purchase of travel insuranceis not required to purchase any other product or service from the travel retailer. You mayalready have coverage that provides similar benefits and you may wish to compare theterms of this coverage with your existing coverage. If you have questions about yourcurrent coverage, call your insurer or agent. The travel retailer is not qualified to answerquestions about the benefits, exclusions or conditions of the travel insurance. TravelexInsurance Services, Inc. 1121 North 102nd Court, Suite 202, Omaha, NE 68114. Toll free1-800-228-9792. Email: customerservice@travelexinsurance.comCalifornia Residents: California Insurance Department: Toll free consumer hotline is1-800-927-7357. Travelex CA Agency License #0D10209New York Residents: The licensed producer represents the insurer for purposes of the sale.Compensation paid to the producer may depend on the policy selected, the producersexpenses or volume of business. The purchaser may request and obtain information aboutthe producer’s compensation except as otherwise provided by law.Travel Insurance is underwritten by Stonebridge Casualty Insurance Company aTransamerica company, Columbus, Ohio; NAIC #10952 (all states except as otherwisenoted) under Policy/Certificate Form series TAHC5000. In CA, HI, NE, NH, PA, TN and TXPolicy/Certificate Form series TAHC5100 and TAHC5200. In IL, IN, KS, LA, OR, OH, VT, WA and WY Policy Form Numbers TAHC5100IPS and TAHC5200IPS. Certain coverages areunder series TAHC6000 and TAHC7000.This brochure is a brief summary of the program, please review theDescription of Coverage for an outline of benefits and amounts of coverageavailable to you. Your Individual Policy or Group Certificate will govern the finalinterpretation of any provision or claim. To view your state-filed form, please visitwww.travelexinsurance.com/SBPlans.aspx or call 1-800-819-9004 to obtain yourIndividual Policy in the following states: IL, IN, KS, LA, OR, OH, VT, WA and WY or your GroupCertificate for all other states. © 2013 Travelex Insurance Services, Inc. 26232037B

Exclusions & Limitations

Travel AgentContact your local travel agent.

InternetVisit us at www.travelexinsurance.com to get a quote, learn more or to purchase.

PhoneSpeak with an experienced customer service representative available at 1-800-504-7883,M-F 8:00 am to 7:00 pm CST, to answer questions, receive a quote or to enroll.

Fax or MailFax both sides of enrollment form to 1-800-867-9531or mail to: Travelex Insurance Services, PO Box641070, Omaha, NE 68164-7070.

Payment Details

65 71013 STS-VIR 0811

In today’s travel environment it’s important to protect you and your trip investment. Meet your travel needs with the customized coverage Travel Select offers and find the peace of mind your trip deserves with these valuable plan highlights:

Primary CoverageEasy claims handling, less time and hassle to receivereimbursement for eligible losses from us first, with no deductibles, before any other collectible insurance.

Kids Included at No Cost!Offering great value to traveling families, children under age 21can be protected at no additional cost when accompaniedby a covered adult family member.

21 Day Pre-Existing WaiverPurchase the plan within 21 days of initial trip deposit and pre-existing medical conditions are eligible for coverage.

Post Departure ProtectionSelect the $0 trip cost level if you don’t need cancellation coverage. Receive all other base plan benefits, plus $1,000 in trip interruption coverage.

Ten Day Free LookIf you are not completely satisfied within 10 days ofpurchasing this plan, Travelex will refund your premium cost, if you have not departed on your trip or filed a claim.

STS-VIR 0811

Travel Select Customizable Travel Protection

Like us on Facebook!facebook.com/TravelexInsurance

7

LOCATION NUMBER AGENT CODE

COMPANY NAME

Please utilize the location number and agent code below when getting a quote or enrolling.

Exclusive Brochure

Check or Money Order (payable to Travelex Insurance Services)

Visa® MasterCard® Discover® American Express®

Credit Card Number

Credit Card Expiration Date

Print Full Name

(As appears on credit card)

Signature (Mandatory for all payment types)

Date

Plan fees are non-refundable after 10 day free look period.

MM / YYYY

___ ___ ___ ___ /___ ___ ___ ___/ /___ ___ ___ ___/ /___ ___ ___ ___/

MM / DD / YYYY

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.

If you wish to obtain a fraud statement specific to your state of residence, please call 1-800-819-9004.

4

Benefit Highlights Customize with Upgrades Enrollment Form

Base Plan Benefits Coverage Per Person†

TrTrTrTT ipipipppppipipp CCCCCCCCCCCananananncecccecellllllllataaataatioioioi nnnnn 1101010001000%0%0%000000% oooooof f f trrrtrrrtrtripipipipipppp ccccccosooosoosososost ttt ttt ($($($($($$($($50505050500505005 ,0,0,0,0,0,0,0,00000000000000000000 lllllimimimmmmmitititiit)))))

TrTTTrTrTTrTTrTripipipipipi IIIIIntntnterereeerrururuptptptioooioioonnn 15155151550%0%0%%%%%00 oooof f f f trtrtrrrrrrripipipipip cccccccososososssost tttttt ($($($$$$$($($757557575555757575,00,0,0,0,0000000000000 limimimmmititit))))

TrTrTripipip DDDelelelayayayayayayy/M/M/M/M/M/Misisissesesedddddd CrCrCruiuiuisesesesese CCConononoo neneneeectctctioioionnn $7$7$77$7505055050

BaBaBaaaaggggggggggggagagagagagge/e/e/e/BaBaBaBaBaBaggggggg agagage e e DeDeDelalalayyy $1$1$1$$ ,0,0,0000000 ///// $$$2525255500000

EmEmEmEmEmEmererereerergegegeggencncncnccncy y yy y y AcAcAcAcAcAccicicidededentntntntntnt &&& SSSicicicknknknesesess s s MeMeMedididicacacal l l ExExExpepepensnsnseee e $5$5$50,0,0,0000000 0 0 00

EmEmEmEEEmmerererergegggeencncncyyy MeMeMeMM dididiicacacalll EvEvEvEEvEvaacaacacccuauauauaatititiitiiononononn/R/R/R/RR/Repepepee atatatriririatatatioioionnnEmEmEmmE erggegegeeegeg ncncncn yyy MeMeMeMeeediddddd cacacacacacall EvEvEvEvEvEvaaaaca uauauatiiono /R/RRR/RRepepepepepepatatatririataatioioionnn $5$5$5000000 000000000$5$5$500000,0,0,0000000

2424 HHoouuuououoourrr r rr AcAcAcAcAcAAcAA ciciccicic dedededededentntntntntn alalalalaa DDDDDDDeaeeeaeeeatthth && DDisismemembmbmbmbmbmmbmm erererererermememememementntntnntnt $2$2$2$2$225,5,5,5,5,5 00000000000000000

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Optional Upgrades

TrTrananspsporortatatitionon PPakak•• FliFlightght AcAccidcidentent ADAD&D&D (pe(per pr perserson)on) $2$20000,0,00000•• RenRentaltal CaCar Dr Damaamagege ProProtectectiotionn (pe(perr plan)) $3$35,5,000000

LiL fefeststylylee PaPaksks CoCoveveraragege vvararieies s byby ppakak

Trip CostUse full cost per person, include all non-refundable, prepaid travel costs.

Base Plan Rates Per Person

Ages0-34

Ages35-59

Ages60-69

Ages 70-79

Ages 80+

$0$0$0$$0$0 excexexcexexcludludludessses ess tritritritritrip cp cp cpp cp cancancancancanc llllelleellatiatatatiation*n*n*on*on****** $25$25$25$25$252 $34$34$34$3$3$34 $50$50$50$50$505 $61$61$61$6$61$61 $11$11$11$11$11$ 33333

$1 - $500 $30 $42 $58 $70 $133

$50101 - $1,000 $50$50 $61 $81 $118 $199

$1,001 - $1,500 $64 $82 $110 $162 $252

$1,$1,501501 - $$2,02,0000 $85$85 $10$1077 $14$1499 $2$2177 $32$322

$2,001 - $2,500 $107 $132 $184 $267 $394

$2,501 - $3,000 $127 $155555 $218 $319 $465

$3,001 - $3,500 $148 $171 $253 $366 $541

$3,$3,501555 - $$4,0444,00000 $16$1688 $18$1844 $28$2888 $42$4222 $63$6388

$4,001 - $4,500 $187 $205 $350 $474 $709

$4,$4,$4,4,$4 5015015015501 ---- $$$$$5,05,05,05,00000000000000 $20$20$20$20$2099999 $22$22$22$229999 $39$39$39$ 444 $52$52$52$52255 $80$$$8011111

$5,001 - $5,500 $241 $269 $441 $609 $936

$5,$5,501501 -- $$6,06,00000000 $26$26$266$2 22222 $30$30$30$30066 $47$47$47$4711111 $65$$65$65$652222 $1,1$1$1$111$1,$1$ 08208208200082008200082

$6,001 - $6,500 $295 $326 $517 $722 $1,264

$6,$6$6,$6$6,5015015015011111 ---- $$$$$$$$$7,07,07,07,07,07,07,07 00000000000000 $31$31$31$31$31$31$31$316666666 $36$36$36$36$36$36$3665555555555 $55$55$55$55$55$55$55$55$55$55$55$55533333333 $76$76$76$76$76$76$76$76$76$76$7 88888888 $1,$1$1$1,1$1,$1,11$1,11 6006006006006600600060060

$7,001 - $8,000 $354 $403 $651 $910 $1,872

$8,$8$8$8,$8,$8 0010010010010010 1 --- $$$$$$$9 09 09,09,09,09999,00000000000000 $40$40$40$403333 $44$44$44$44$44$44$4411111 $72$72$72$72$72$72$72222222 $1,$1,$1,$1$1,$1 019019010019019 $1,$1,$1,$1,$1$1 90290290290290290902902

$9,001 - $10,000 $425 $478 $750 $1,135 $1,942

Benefits & Rates

Primary Traveler Full Name

Birth Date Trip Cost

Second Traveler Full Name

Birth Date Trip Cost

Third Traveler Full Name

Birth Date Trip Cost

Fourth Traveler Full Name

Birth Date Trip Cost

Please print clearly for accurate processing.

MM / DD / YYYY $

Trip Details

MM / DD / YYYY $

MM / DD / YYYY $

MM / DD / YYYY $

Address

City State Zip

Daytime Phone

Beneficiary Name(Estate designated if left blank)

Primary Traveler Email(Provide to receive Confirmation of Coverage via email)

2222222222211111111 3333333333

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Total Base Plan Rate (calculate below for all travelers)

Trips 31-180 days in length (include arrival and departure days) # travelers # days over 30

Optional Transportation Pak k ($59)

Optional Lifestyle Paks Active Family Pak ($49) Adventurer Plus Pak ($49)

Professional Pak ($99)

Processing Fee

Total Amount Due(and authorized as payment)

$

$ 8.00

$

$ $ $ $ + + + $ =

x x $8 $ =

$

Primary Traveler Second Traveler Third Traveler Fourth Traveler Base Plan Total

Extra Days Total

Departure Date Return Date

Traveler Details

Location Number / Agent Code(on pg 7 of brochure)

MM / DD / YYYY

Country of Destination

Tour Operator

MM / DD / YYYY

Cruise Line Airline

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Premium Calculation

For questions, quotes or to enroll, visit www.travelexinsurance.com

or call 1-800-504-7883

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PaPasssspoportrt/V/Visisa a ThThefeftt Active Family Pak Additional $49 Per Plan

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Adventurer Plus Pak Additional $49 Per Plan

Providdese aa rental allowance in case ee ofofof lllososost,t,t, ssstototolelelennnd d ti i t WWWor damaged sporting equipment.t.t. WWW i bbbaiaiaivevevesss bababasesese

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Professional Pak Additional $99 Per Plan

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APoppsppaaS

STS-VIR 0811 STS VIR 0811TAHC5001GES

† Coverage is up to the limits shown per person. Limitations and exclusions apply.

54

Enrollment Options Enrollment Form

Primary Traveler Full Name

Birth Date Trip Cost

Second Traveler Full Name

Birth Date Trip Cost

Third Traveler Full Name

Birth Date Trip Cost

Fourth Traveler Full Name

Birth Date Trip Cost

Please print clearly for accurate processing.

MM / DD / YYYY $

Trip Details

MM / DD / YYYY $

MM / DD / YYYY $

MM / DD / YYYY $

Address

City State Zip

Daytime Phone

Beneficiary Name(Estate designated if left blank)

Primary Traveler Email(Provide to receive Confirmation of Coverage via email)

Total Base Plan Rate (calculate below for all travelers)

Trips 31-180 days in length(include arrival and departure days) # travelers # days over 30

Optional Transportation Pak k ($59)

Optional Lifestyle Paks Active Family Pak ($49) Adventurer Plus Pak ($49)

Professional Pak ($99)

Processing Fee

Total Amount Due(and authorized as payment)

$

$ 8.00

$

$ $ $ $ + + + $ =

x x $8 $ =

$

Primary Traveler Second Traveler Third Traveler Fourth Traveler Base Plan Total

Extra Days Total

Departure Date Return Date

Traveler Details

Location Number / Agent Code(on pg 7 of brochure)

MM / DD / YYYY

Country of Destination

Tour Operator

MM / DD / YYYY

Cruise Line Airline

Premium Calculation

Travel AgentContact your local travel agent.

InternetVisit us at www.travelexinsurance.com to get a quote, learn more or to purchase.

PhoneSpeak with an experienced customer servicerepresentative available at 1-800-504-7883,M-F 8:00 am to 7:00 pm CST, to answer questions,receive a quote or to enroll.

Fax or MailFax both sides of enrollment form to 1-800-867-9531or mail to: Travelex Insurance Services, PO Box641070, Omaha, NE 68164-7070.

Payment Details

STS-VIR 0811 TAHC5001GES

Check or Money Order (payable to Travelex Insurance Services)

Visa® MasterCard® Discover® American Express®

Credit Card Number

Credit Card Expiration Date

Print Full Name(As appears on credit card)

Signature (Mandatory for all payment types)

Date

Plan fees are non-refundable after 10 day free look period.

MM / YYYY

___ ___ ___ ___ /___ ___ ___ ___/ /___ ___ ___ ___ / /___ ___ ___ ___/

MM / DD / YYYY

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 guiltyof a crime and may be subject to fines and confinement in prison.

If you wish to obtain a fraud statement specific to your state of residence, please call 1-800-819-9004.

MM / YYYY

___ ___ ___ ___ ///___ ___ ___ ___ / ///___ ___ ___ ___ / ///___ ___ ___ ___ /