Purchase

Student Leadership University

Traveler Information (enter travelers here)

Primary Traveler

Trip Cost for Primary Traveler

(U.S. Dollars)

First Name

Middle Initial

Last Name

Date of Birth

m / d / yyyy

Confirm Email

Country

Street Address or P.O. Box

Address Line 2

City

State

Zip Code

Traveler 2

Please note that all travelers listed on this policy must reside at the same address.

Trip Cost for Traveler 2

(U.S. Dollars)

First Name

Middle Initial

Last Name

Date of Birth

m / d / yyyy

Traveler 3

Trip Cost for Traveler 3

(U.S. Dollars)

First Name

Middle Initial

Last Name

Date of Birth

m / d / yyyy

Traveler 4

Trip Cost for Traveler 4

(U.S. Dollars)

First Name

Middle Initial

Last Name

Date of Birth

m / d / yyyy

Traveler 5

Trip Cost for Traveler 5

(U.S. Dollars)

First Name

Middle Initial

Last Name

Date of Birth

m / d / yyyy

Traveler 6

Trip Cost for Traveler 6

(U.S. Dollars)

First Name

Middle Initial

Last Name

Date of Birth

m / d / yyyy

Traveler 7

Trip Cost for Traveler 7

(U.S. Dollars)

First Name

Middle Initial

Last Name

Date of Birth

m / d / yyyy

Traveler 8

Trip Cost for Traveler 8

(U.S. Dollars)

First Name

Middle Initial

Last Name

Date of Birth

m / d / yyyy

Traveler 9

Trip Cost for Traveler 9

(U.S. Dollars)

First Name

Middle Initial

Last Name

Date of Birth

m / d / yyyy

Traveler 10

Trip Cost for Traveler 10

(U.S. Dollars)

First Name

Middle Initial

Last Name

Date of Birth

m / d / yyyy

Primary Traveler Telephone(s) (policy telephones)

International

Phone

Phone Type

International

Phone

Phone Type

Trip Information (dates, destination & carriers)

Departure Date

m / d / yyyy

Return Date

m / d / yyyy

Trip Length 9 days

Initial Trip Deposit Date

m / d / yyyy

Trip Destinations

Legacy Destination

Upgrades & Options (choose additional coverage here)

Optional Cancel For Any Reason

75% Price shown is for all travelers. Must be purchased within 14 days of your initial trip deposit date

$0.00

Beneficiaries (optional)

Designation of a beneficiary is optional.

Primary Traveler

First Name	Middle Initial	Last Name	%
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler

Traveler 2

First Name	Middle Initial	Last Name	%
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler

Traveler 3

First Name	Middle Initial	Last Name	%
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler

Traveler 4

First Name	Middle Initial	Last Name	%
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler

Traveler 5

First Name	Middle Initial	Last Name	%
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler

Traveler 6

First Name	Middle Initial	Last Name	%
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler

Traveler 7

First Name	Middle Initial	Last Name	%
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler

Traveler 8

First Name	Middle Initial	Last Name	%
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler

Traveler 9

First Name	Middle Initial	Last Name	%
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler

Traveler 10

First Name	Middle Initial	Last Name	%
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler
	Optional		Combined beneficiary percentages must total 100% for each traveler

Agency (agency information if applicable)

Agency Number

Agent

Plan Document Delivery (how do you want to receive your documents?)

Delivery Method

Emailed

Your Confirmation of Benefits and Plan Document will be emailed to you immediately after purchase.

To send a copy to another email address, enter it below.

Delivery Email

Confirm Delivery Email

Payment (enter payment information here)

Payment #1

Amount

Card Number

YYYY

Card Security Code

Name on Card

First

Middle

Optional

Last

Billing address is same as primary traveler's address

Country

Street Address or P.O. Box

Address Line 2

City

State

Zip Code

Payment #2

Amount

Card Number

YYYY

Card Security Code

Name on Card

First

Middle

Optional

Last

Billing address is same as primary traveler's address

Country

Street Address or P.O. Box

Address Line 2

City

State

Zip Code

Payment #3

Amount

Card Number

YYYY

Card Security Code

Name on Card

First

Middle

Optional

Last

Billing address is same as primary traveler's address

Country

Street Address or P.O. Box

Address Line 2

City

State

Zip Code

I have read the Purchase Agreement and Plan Document

Refund (enter refund information here)

Refund Fee

Check

Amount