APPLICATION PROCEDURE

To apply for travel insurance, please complete the following form with CREDIT CARD information. If you prefer, you may apply for coverage using one of the following options:

FAX an application, using our printable form

- or -
CALL 888/ 811-6363 with your credit card information.
Upon receipt of your application and premium payment, we will email you a confirmation.

Personal Information


	Name:
	Street Address:
	City:
	State:
	Zip Code:
	Area Code/Telephone:
	2nd Telephone:
	Fax Telephone:
	Email Address:

Credit Card Information

Secure Server Application Process

Type credit card:

Credit Card Number:

Expires:

Cardholder Name:

Today's Date:

Travel Information

	Departure Date:
	Return Date:
	Destination(s):
	Reserved via:	Colorado Resort Reservations
	Travel Agency:
	Agent Phone:
	Booking Number:

Premium Calculation

	Name	Age	Premium
*Applicant #1*
*Applicant #2*
*Applicant #3*
*Applicant #4*
*Applicant #5*
*Applicant #6*
*Applicant #7*
*Total Gross Premium*
*Total Amount Due*

You are presently on a SECURE SERVER which facilitates both your privacy and protection from potential fraud. If you are uncomfortable with the online application process, feel free to e-mail, fax, phone or mail your application and payment.