JCC Insurance - Ayelet Tours, Ltd.

Name *

First

Middle

Last

Traveler Email *

Phone Number *

Group Insurance *

For your convenience, we offer a travel insurance plan through Travelex Insurance Services. For more information and rates, refer to the 360° Group Choice flyer above. Travel insurance is offered on behalf of and under the direction of Travelex Insurance Services. If selecting Yes, you acknowledge that you have read and understand the policy, which includes the full coverage term details, including exclusions and limitations, and Travel Protection Plan flyer, which includes important consumer information, plan highlights, and rates. To view/download the policy, visit: https://policy.travelexinsurance.com/GCB-0521 To view state specific fraud warnings, visit: https://www.travelexinsurance.com/company/fraud-warning. Travelex Insurance Services Inc. (“Travelex Insurance”) maintains an updated list of alerts and financial defaults on its website available at https://www.travelexinsurance.com/customer-service/travel-alerts/travel-supplier. Please visit https://partner.travelexinsurance.com/docs/tis/marketing/ny-phn-covid-19-comp.pdf?sfvrsn=300e81a4_4 to view a special notice for NY residents regarding coverage related to COVID-19. Travelex Insurance Services, Inc. CA Agency License #0D10209. Travel Insurance is underwritten by Berkshire Hathaway Specialty Insurance Company; NAIC #22276. 7I6

Trip Deposit Date (date you sent first payment for your Ride for the Living registration)

Number of people requesting coverage, age 25 and above: *

Please include your flight cost when deciding total coverage per person. Coverage available to US citizens only.

Number of people requesting coverage, age 24 and below: *

Insurance Coverage Covered party 1 (Age 25 and above) *

Date of Birth Covered party 1 (Age 25 and above) *

Address Covered party 1 (Age 25 and above) *

Address Line 1

Address Line 2

City

State

Zip Code

Departure date from North America Covered party 1 (Age 25 and above) *

Return date to North America Covered party 1 (Age 25 and above) *

Covered party 2 (Age 25 and above)

Name Covered party 2 (Age 25 and above) *

First

Middle

Last

Insurance Coverage Covered party 2 (Age 25 and above) *

Date of Birth Covered party 2 (Age 25 and above) *

Address Covered party 2 (Age 25 and above) *

Same as Covered party 1
New adress

Address Covered party 2 (Age 25 and above) *

Address Line 1

Address Line 2

City

State

Zip Code

Travel Dates Covered party 2 (Age 25 and above) *

Same as Covered party 1
Different Travel Dates

Departure date from North America Covered party 2 (Age 25 and above) *

Return date to North America Covered party 2 (Age 25 and above) *

Covered party 3 (Age 25 and above)

Name Covered party 3 (Age 25 and above) *

First

Middle

Last

Insurance Coverage Covered party 3 (Age 25 and above) *

Date of Birth Covered party 3 (Age 25 and above) *

Address Covered party 3 (Age 25 and above) *

Same as Covered party 1
New adress

Address Covered party 3 (Age 25 and above) *

Address Line 1

Address Line 2

City

State

Zip Code

Travel Dates Covered party 3 (Age 25 and above) *

Same as Covered party 1
Different Travel Dates

Departure date from North America (Adult 3) *

Return date to North America (Adult 3) *

Covered party 1 (Age 24 and below)

Name Covered party 1 (Age 24 and below) *

First

Middle

Last

Date of Birth Covered party 1 (Age 24 and below) *

Insurance Coverage Covered party 1 (Age 24 and below) *

Address Covered party 1 (Age 24 and below) *

Same as Covered party 1
New adress

Address Covered party 1 (Age 24 and below) *

Address Line 1

Address Line 2

City

State

Zip Code

Travel Dates Covered party 1 (Age 24 and below) *

Same as Covered party 1
Different Travel Dates

Departure date from North America Covered party 1 (Age 24 and below) *

Return date to North America Covered party 1 (Age 24 and below) *

Covered party 2 (Age 24 and below)

Name Covered party 2 (Age 24 and below) *

First

Middle

Last

Date of Birth Covered party 2 (Age 24 and below) *

Insurance Coverage Covered party 2 (Age 24 and below) *

Address Covered party 2 (Age 24 and below) *

Same as Covered party 1
New adress

Address Covered party 2 (Age 24 and below) *

Address Line 1

Address Line 2

City

State

Zip Code

Travel Dates Covered party 2 (Age 24 and below) *

Same as Covered party 1
Different Travel Dates

Departure date from North America Covered party 2 (Age 24 and below) *

Return date to North America Covered party 2 (Age 24 and below) *

Cancelation Terms *

I agree with the below terms

The insurance payment is refundable minus $50 processing fee until 90 days prior to departure. Within 90 days, the insurance cost is non-refundable. You will receive policy number and full policy details approximately 30 days prior to departure.