ASSURANCE INTERNATIONALE
www.assurance-reseau.com

Please Print for careful review.
Ask yourself...
Are you knowledgeable enough to make the right decisions during a foreign medical emergency?
Do you know where the best hospitals and doctors are?
Do you know local customs, laws, and requirements?
Air ambulances are unregulated, do you know which ones are best?
Would you know how to coordinate a medical transport?
Could you arrange for a trained medical escort?
Can you or your doctors communicate in the local language?
Do you have a local advocate to cut through red tape and make service and financial arrangements?
Do you know what should be charged for emergency service?

With TAI you get these services and many, many more.

Don't jeopardize your life or risk financial ruin. Most health insurance plans do not provide services for emergency medical evacuation, repatriation, or return of mortal remains.

A single call gives you expertise and immediate response.

TAI is the industry leader, and has been providing quality trip assurance for almost 40 years.

That means reliability, confidence, and trust when you need it most. Make your travel worry free.

TAI offers flexible plans and high limits to meet your travel needs.

With TAI you can get next day coverage. Use the Internet for immediate registration and confirmation.

 
 
You're away from home and you need help. Who do you call? With Travel Assistance International (TAI), you can call us anytime, anywhere you are. One toll-free or collect call can save you time, money, and even your life.

Medical Assistance
Emergency Medical Evacuation, Medically necessary repatriation, On-the-spot emergency medical payments, Repatriation of remains, Referrals to physicians & hospitals, Round-the-clock medical monitoring, Return of dependent children, Return of traveling companion, Vehicle return, Meals and accommodations.

Insurance Benefits
Various options available. Coverage for both short and long trips. Options for Medical and Trip Cancellation, Individual and Family options.

Travel Assistance
Emergency travel arrangements & ticketing, Emergency cash advance, Referrals to attorneys, Bail bond posting, Luggage tracking, Lost document assistance, Prescription replacement or refill assistance, Eyeglasses replacement assistance, Emergency message relay, Interpretation by Telephone.

Pre-Trip Assistance
Country-specific information, Visa & Passport Requirements, Inoculation & immunization requirements, Foreign exchange rates, Weather forecasts, Embassy & consular information, U.S. State Department travel advisories.

All services must be approved or arranged in advance by Worldwide Assistance Services.

 

Base Program Benefits *
Benefit
Plan A
Plan B
Plan C
Medical Coverage
$60,000
$15,000
-
Emergency Medical Evacuation
$1,000,000
$1,000,000
$1,000,000
Medically Necessary Repatriation
$1,000,000
$1,000,000
$1,000,000
Repatriation of Remains
$1,000,000
$1,000,000
$1,000,000
24 Hour Accidental Death & Dismemberment
$10,000
$10,000
$10,000
Visit by Family Member
$1,000
$1,000
$1,000
Return of Traveling Companion
$1,000
$1,000
$1,000
Return of Dependent Children
$1,000
$1,000
$1,000
Vehicle Return
$1,000
$1,000
$1,000
Meals/Accomodations
$100/day/10days
$100/day/10days
$100/day/10days

* Group and Corporate Rates Available.
* Benefit limits are reduced by 50% for members over 74.

Base Program Prices
 
US Citizens & Residents
Eligibility
Plan A
Plan B
Plan C
Days
Individual
Family
Individual
Family
Individual
Family
1 to 8
$95
$120
$65
$95
$25
$45
Up to 15
$105
$135
$75
$115
$30
$55
Up to 31
$130
$185
$105
$165
$40
$75
Each additional 30 days.
$100
$175
$70
$145
$30
$60
Annual *
$305
$565
$235
$465
$90
$190

* Annual represents coverage for frequent travelers. Maximum trip length is 90 days.

Prices for Trip Cancellation, Interruption*, and Baggage Loss/Delay**
* $1,000 limit for trip interruption.
** $100 deductible/person/occurrence, $1,000 limit/person
Total Trip Cost
Individual Price
Family Price
0 - $500
$30
$40
$501 - $1,000
$65
$85
$1,001 - $1,500
$105
$135
$1,501 - $2,000
$140
$175
$2,001 - $2,500
$175
$215
$2,501 - $3,000
$210
$255
$3,001 - $3,500
$245
$295
$3,501 - $4,000
$280
$335
$4,001 - $4,500
$315
$375
$4,501 - $5,000
$350
$415
$5,001 - $5,500
$385
$455
$5,501 - $6,000
$420
$495
$6,001 - $6,500
$455
$535
$6,501 - $7,000
$490
$575
$7,001 - $7,500
$525
$615
$7,501 - $8,000
$560
$655
$8,001 - $8,500
$595
$695
$8,501 - $9,000
$630
$735
$9,001 - $9,500
$665
$775
$9,501 - $10,000
$700
$815

ASSURANCE INTERNATIONALE
www.assurance-reseau.com

Please Print for careful review.
Ask yourself...
Are you knowledgeable enough to make the right decisions during a foreign medical emergency?
Do you know where the best hospitals and doctors are?
Do you know local customs, laws, and requirements?
Air ambulances are unregulated, do you know which ones are best?
Would you know how to coordinate a medical transport?
Could you arrange for a trained medical escort?
Can you or your doctors communicate in the local language?
Do you have a local advocate to cut through red tape and make service and financial arrangements?
Do you know what should be charged for emergency service?

With TAI you get these services and many, many more.

Don't jeopardize your life or risk financial ruin. Most health insurance plans do not provide services for emergency medical evacuation, repatriation, or return of mortal remains.

A single call gives you expertise and immediate response.

TAI is the industry leader, and has been providing quality trip assurance for almost 40 years.

That means reliability, confidence, and trust when you need it most. Make your travel worry free.

TAI offers flexible plans and high limits to meet your travel needs.

With TAI you can get next day coverage. Use the Internet for immediate registration and confirmation.

 
 
You're away from home and you need help. Who do you call? With Travel Assistance International (TAI), you can call us anytime, anywhere you are. One toll-free or collect call can save you time, money, and even your life.

Medical Assistance
Emergency Medical Evacuation, Medically necessary repatriation, On-the-spot emergency medical payments, Repatriation of remains, Referrals to physicians & hospitals, Round-the-clock medical monitoring, Return of dependent children, Return of traveling companion, Vehicle return, Meals and accommodations.

Insurance Benefits
Various options available. Coverage for both short and long trips. Options for Medical and Trip Cancellation, Individual and Family options.

Travel Assistance
Emergency travel arrangements & ticketing, Emergency cash advance, Referrals to attorneys, Bail bond posting, Luggage tracking, Lost document assistance, Prescription replacement or refill assistance, Eyeglasses replacement assistance, Emergency message relay, Interpretation by Telephone.

Pre-Trip Assistance
Country-specific information, Visa & Passport Requirements, Inoculation & immunization requirements, Foreign exchange rates, Weather forecasts, Embassy & consular information, U.S. State Department travel advisories.

All services must be approved or arranged in advance by Worldwide Assistance Services.

 

Base Program Benefits *
Benefit
Plan A
Plan B
Plan C
Medical Coverage
$60,000
$15,000
-
Emergency Medical Evacuation
$1,000,000
$1,000,000
$1,000,000
Medically Necessary Repatriation
$1,000,000
$1,000,000
$1,000,000
Repatriation of Remains
$1,000,000
$1,000,000
$1,000,000
24 Hour Accidental Death & Dismemberment
$10,000
$10,000
$10,000
Visit by Family Member
$1,000
$1,000
$1,000
Return of Traveling Companion
$1,000
$1,000
$1,000
Return of Dependent Children
$1,000
$1,000
$1,000
Vehicle Return
$1,000
$1,000
$1,000
Meals/Accomodations
$100/day/10days
$100/day/10days
$100/day/10days

* Group and Corporate Rates Available.
* Benefit limits are reduced by 50% for members over 74.

Base Program Prices
 
US Citizens & Residents
Eligibility
Plan A
Plan B
Plan C
Days
Individual
Family
Individual
Family
Individual
Family
1 to 8
$95
$120
$65
$95
$25
$45
Up to 15
$105
$135
$75
$115
$30
$55
Up to 31
$130
$185
$105
$165
$40
$75
Each additional 30 days.
$100
$175
$70
$145
$30
$60
Annual *
$305
$565
$235
$465
$90
$190

* Annual represents coverage for frequent travelers. Maximum trip length is 90 days.

Prices for Trip Cancellation, Interruption*, and Baggage Loss/Delay**
* $1,000 limit for trip interruption.
** $100 deductible/person/occurrence, $1,000 limit/person
Total Trip Cost
Individual Price
Family Price
0 - $500
$30
$40
$501 - $1,000
$65
$85
$1,001 - $1,500
$105
$135
$1,501 - $2,000
$140
$175
$2,001 - $2,500
$175
$215
$2,501 - $3,000
$210
$255
$3,001 - $3,500
$245
$295
$3,501 - $4,000
$280
$335
$4,001 - $4,500
$315
$375
$4,501 - $5,000
$350
$415
$5,001 - $5,500
$385
$455
$5,501 - $6,000
$420
$495
$6,001 - $6,500
$455
$535
$6,501 - $7,000
$490
$575
$7,001 - $7,500
$525
$615
$7,501 - $8,000
$560
$655
$8,001 - $8,500
$595
$695
$8,501 - $9,000
$630
$735
$9,001 - $9,500
$665
$775
$9,501 - $10,000
$700
$815

 

How to Apply for TAI
  1. Pick a Base Program that matches your needs (Plan A, B, or C) and the time period that matches the length of your trip.
  2. Take the rate that applies, either Individual or Family prices, and insert that premium in the first box of the application.
  3. Add the Optional Coverage (if desired).
  4. Complete the application and send to the Administrator along with the corresponding payment.
  5. The Administrator will process the application and send you an ID Card by mail. Or apply online and receive confirmation immediately! (including ID number)

Application

Applicant Information
Distributor ID#: 6643 PGranger
Please circle one: First-Time Applicant or
Previously purchased (previous Membership#___)
Mr. Mrs. Ms
Last Name:

 

First: MI:
U.S. Address:

 

City:

 

St: Zip:
Day Phone:
 
Evening Phone:
Where are you traveling?
 
How did you hear about TAI?:
 

Coverage Dates - Your membership will begin and end on the dates you have selected, provided balid payment has been received. Coverage will begin no sooner than the postmark date on your application or 12:01 AM EST the day following receipt of your application. Notice: Coverage must be purchased prior to trip departure.

Starting 12:01 AM (local time)

month

day

year
Ending 11:59 PM (local time)

month

day

year

Applicants - In addition to yourself, the Family Plan coves your spouse & dependent children up to age 19 or less than age 23 if full-time student.

1/Applicant

 
Date of Birth
2/Spouse

 
Date of Birth
3/Dependent

 
Date of Birth
4/Dependent

 
Date of Birth
5/Dependent

 
Date of Birth

 

Payment Calculation - Please select your desired Membership Plan and, if desired, Optional Coverage from the Membership Plan table. Fees are subject to change without notice. Membership Fees are non-refundable after the effective date. Membership is non-transferable. All coverage is secondary:

Membership Plan (please choose, A, B, C or Frequent Traveler and then Individual or Family)
_Plan A _Plan B _Plan C
_Frequent Traveler
_Individual _ Family
$
Optional Coverage (only available on a per trip basis)
Trip Cancellation/Interruption
Baggage/Delay
 
Trip Cost $_________
 
$
Accidental Death & Dismemberment - Air Common Carrier
__ $100,000 - $5/person/trip
__ $250,000 - $10/person/trip
__ $500,000 - $20/person/trip

Beneficiary: ______________

 
$
Membership Fee:
$ 5.00
Total Amount Due:
$

Payment Options
___ Check or money order in U.S. dollars, drafted on a U.S. bank, made payable to Travel Assistance International

U.S. Citizens only, others call for additional available programs.

__ Charge to: __ Visa
__ American Express
__ Diners Club

 
__ Mastercard
__ Discover
Card#:
Expiration Date:
Name on Card:
Signature:

Applicant Release
I hereby enroll in Travel Assistance International. I authorize to, or by Travel Assistance International of any information necessary to process this application and any claims. A photocopy or fax of this authorization is acceptable as an original. Information contained on this application found later to be inaccurate shall void all coverage benefits. If signed as agent of the applicant the undersigned warrants his/her authority and capacity to so act. Please refer to the Description of Coverage for details of coverage, terms, conditions, limitations and exclusions. All services must be approved or arranged by Worldwide Assistance Services. The benefits under Section II are underwritten by Virginia Surety Company, Inc., 123 North Wacker Drive, Chicago, IL 60606.

Signature:___________________________

Date: ______________________

TAI Administrators
9200 Keystone Crossing, Ste 300
Indianapolis, IN 46240
To Apply fax application to 954-893-7916

Description of Services
Section I
Emergency Evacuation/Medically Necessary Repatriation:
WA will provide for covered expenses as shown above if an Injury or Sickness commencing during the course of the covered Trip results in Your necessary Emergency Evacuation. Covered Expenses are reasonable and customary expenses for medically necessary transportation, medical services, and medical supplies incurred in connection with Your Emergency Evacuation. All transportation arrangements made for Your evacuation must be made by WA and be by the most direct and economical route possible.

Repatriation of Remains: WA will pay reasonable covered expenses incurred to return Your body to Your place of residence if You die during the covered Trip. Covered expenses include expenses for: embalming, cremation, minimally necessary container for transport, and transportation.

Visit by Family Member of Friend: When You are traveling alone, and are hospitalized for more than seven (7) consecutive days, WA will arrange and pay for the cost of transportation, up to the maximum shown, to the place of hospitalization for one person chosen by You, provided medical repatriation is not imminent. Covered expenses are limited to the cost of the most direct economy round-trip common carrier ticket to the place of hospitalization.

Return of Dependent Children/Grandchildren: When Dependent Children, traveling under this plan, are with You, and are left unattended as a result of Your hospitalization, WA will reimburse the cost to transport, up to the maximum shown, for such minors to the domicile of a person nominated by You or next of kin. Covered expenses are limited to a one-way common carrier economy ticket by the most direct route. Expenses for attendants will be provided if necessary.

Return of Traveling Companion: If You are hospitalized and it is necessary for Your Traveling Companion to remain with You, thereby interrupting their pre-arranged travel itinerary, and causing their original ticket to be invalid, WA will pay for the lesser of either a new one-way economy class ticket to return the Traveling Companion to their original return destination or charges incurred to change the original ticket to a new return date.

Vehicle Return Service: Any non-commercial vehicle (i.e. auto, motor home, rental cars, etc.) left unattended or if you are physically unable to operate as a result of Your medical emergency, will be returned to Your residence or place of rental. The vehicle must be in good driving condition and capable of being driven on the highway in compliance with local laws. You will not be reimbursed for services provided to You at no cost. $1,000 maximum.

Meals and Accommodations: If Your Traveling Companion is hospitalized, WA will pay for expenses incurred by You, up to $100 per day to a maximum of 10 days, for reasonable additional accommodation and transportation expenses incurred to remain near Your Traveling Companion.


Section II
Emergency Accident & Emergency Sickness Medical Expenses:
The Insurer will pay benefits, up to the maximum shown on the Membership Confirmation Letter, subject to a $100 per person deductible per occurrance, if You incur covered medical expenses for a Sickness or an accidental Injury occurring during the course of the scheduled Trip. You must receive the Emergency Treatment during the course of the scheduled Trip and upon recommendation of the attending Physician. If You are hospitalized (due to a Sickness or an accidental Injury which first occurred during the course of the scheduled Trip) beyond the date of Your scheduled return, coverage will be extended until You are released from the hospital or until maximum benefits under the policy have been paid. Covered medical expenses are medically necessary services and supplies which are recommended by the attending Physician. They include services of a legally qualified Physician, surgeon, graduate nurse, dentist, or osteopath; charges for semi-private hospital confinement and use of operating rooms; charges for anesthetics (including administration), x-ray examinations or treatments, and laboratory tests; ambulance service, drugs, medicine, therapeutic services and supplies. The Insurer will not pay benefits in excess of the reasonable and customary charges commonly used by providers of medical care in the locality in which the care is furnished.

Accidental Death & Dismemberment: If Injury to You, during Your covered Trip results in any of the following losses within 180 days of the date of a covered accident, the Insurer, subject to the maximum amount stated in Your Membership Confirmation Letter, will pay the largest applicable amount as follows: The full benefit amount is paid for loss of: Life, Both Hands or Both Feet, Entire Sight of Both Eyes, One Hand and One Foot, Either Hand or Foot & Entire Sight of One Eye, Speech plus Hearing in Both Ears, One-Half of the benefit is paid for loss of: One Hand or One Foot, Speech, Hearing in Both Ears, Entire Sight of One Eye, One-Quarter of the benefit amount is paid for loss of: Thumb and Index Finger of the Same Hand. Loss with regard to hand or foot means actual severance through or above the wrist or ankle joints; eye means entire and irrecoverable loss of sight; speech or hearing means entire and irrecoverable loss of speech or hearing of both ears; thumb and index finger means actual severance through or above the joint that meets the finger at the palm. Disappearance: The Insurer will pay benefits for loss of life if Your body cannot be located one year after the disappearance of the conveyance in which You were a Passenger due to forced landing, standing, sinking, or wrecking.

Option Coverages: A complete description of optional services are included in the Description of Coverage.

A complete Description of Coverage will be sent with your membership confirmation.

For more information please contact:
Pierre Granger AAI,CIRMS
Managing General Agent
Assurance Internationale Website www.assurance-reseau.com
Email: Pierre Granger

Ph:    1(954) 328 6750
Fax: 1-(305)556-3680

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