<html> <body> <form-template> <fields><field type="text" subtype="text" required="true" label="Email" className="form-control" name="email"></field> <field type="header" subtype="h2" label="Travel Insurance"/> <field type="header" subtype="h1" label=" "/> <field type="header" subtype="h1" label="Annual Vs. Trip Specific Travel Insurance"/> <field type="paragraph" subtype="p" label="What's the difference? Both plans will cover a similar list of benefits including trip interruption, travel delay, baggage delay,&nbsp; emergency medical and dental coverage, rental car damage and theft. An annual plan automatically covers every sing trip your family takes for that year, whether for vacation or work.&nbsp; The key difference is the trip cancellation benefit.&nbsp; Annual plans have a total amount attributed for the whole year, a cancellation amount of $5K, $10K, and it tops at $15K for the year.&nbsp; The Allianz All Trips Premier Annual Plans start at around $600&nbsp; for $5K and top at around $1400 for the $15K benefit. If your trip's value is more than $15K, you may want to purchase a trip-specific policy that can cover much higher cancellation amounts for listed reasons. Typically, a plan must be purchased within 14 days of the orginal trip deposit to benefit from full cancellation coverage.&nbsp;"/> <field type="header" subtype="h1" label="Medical Evacuation and Global Rescue Insurance"/> <field type="paragraph" subtype="p" label="MedjetAssist® is the premier air medical transport membership program for travelers. If you are hospitalized 150 miles or more from home, Medjet will arrange air medical transport back to your hospital of choice in your home country — regardless of medical necessity. Most travel insurances and platinum card benefits programs will only get you to the “nearest acceptable facility”.&nbsp; $425 per year for a family when all under 75.&nbsp; &nbsp;Medjet Horizon members have all medical transport benefits plus added travel security and crisis response services benefits powered by corporate security experts FocusPoint International. Approximately $614 when travelers in same family are under 75."/> <field type="checkbox-group" label="I'm interested in this type of insurance (prices estimated above)" name="im-interested-in-this-type-of-insurance-prices-estimated-above"> <option label="Annual family insurance that covers all personal and business travel within one year" value="annual-family-insurance-that-covers-all-personal-and-business-travel-within-one-year">Annual family insurance that covers all personal and business travel within one year</option> <option label="Trip insurance for a specific trip (Required to cover trip expenses greater than $15K)" value="trip-insurance-for-a-specific-trip-required-to-cover-trip-expenses-greater-than-15k">Trip insurance for a specific trip (Required to cover trip expenses greater than $15K)</option> <option label="Cancel For Any Reason Insurance Upgrade" value="cancel-for-any-reason-insurance-upgrade">Cancel For Any Reason Insurance Upgrade</option> <option label="Medical Evacuation Annual Insurance from Medjet " value="medical-evacuation-annual-insurance-from-medjet-">Medical Evacuation Annual Insurance from Medjet </option> <option label="Medical Evacuation and Global Rescue Annual Insurance " value="medical-evacuation-and-global-rescue-annual-insurance-">Medical Evacuation and Global Rescue Annual Insurance </option> </field> <field type="header" subtype="h1" label="Amount of Cancellation Benefit in an Annual Plan"/> <field type="checkbox-group" label="The is the Allianz All Trips Premier Annual Plan" name="the-is-the-allianz-all-trips-premier-annual-plan"> <option label="$2,000" value="2000">$2,000</option> <option label="$5,000" value="5000">$5,000</option> <option label="$10,000" value="10000">$10,000</option> <option label="$15,000" value="15000">$15,000</option> </field> <field type="header" subtype="h1" label="Amount of Trip Coverage Required"/> <field type="text" label="For Policies that Cover A Single Trip&nbsp; Costing over $15K" name="for-trips-costing-over-15k-recommended" subtype="text" className="form-control"/> <field type="date" required="true" label="Departure of specific trip or starting date of annual plan&nbsp;" name="departure-or-starting-date-of-annual-plan" className="form-control"/> <field type="date" label="Return&nbsp; date for trip specific trips" name="return-date-for-trip-specific-trips" className="form-control"/> <field type="text" label="For plans that cover a specifc trip that costs over $15K, please list countries visiting, your airlines, as well as any cruise companies or tour companies&nbsp;" name="please-list-countries-visiting-your-airlines-as-well-as-any-cruise-companies-or-tour-companies-you-are-using-on-this-trip-if-the-trip-is-valued-over-15k" subtype="text" className="form-control"/> <field type="header" subtype="h1" label="Family Names, Dates of Birth, Household Address"/> <field type="text" required="true" label="First name" name="first-name" subtype="text" className="form-control"/> <field type="text" required="true" label="Last name" name="last-name" subtype="text" className="form-control"/> <field type="text" required="true" label="Your Date of Birth (DOB)" name="your-date-of-birth-dob" subtype="text" className="form-control"/> <field type="text" required="true" label="Other family members' full names and DOBs in the same household" name="other-family-members-full-names-and-dobs-in-the-same-household" subtype="text" className="form-control"/> <field type="text" required="true" label="Line 1" name="address-line-1" subtype="text" className="form-control"/> <field type="text" label="Line 2" name="address-line-2" subtype="text" className="form-control"/> <field type="text" required="true" label="City" name="address-city" subtype="text" className="form-control"/> <field type="text" required="true" label="State" name="address-state" subtype="text" className="form-control"/> <field type="text" required="true" label="Zip" name="address-zip" subtype="text" className="form-control"/> <field type="text" required="true" label="Country" name="address-country" subtype="text" className="form-control"/> <field type="paragraph" subtype="p" label="By signing below, I understand that declining travel insurance could result in the loss of my travel cost and/or require more money to correct the situation. I also acknowledge that without insurance, there may be no way to recoup any losses, costs or expenses incurred.&nbsp;"/> <field type="radio-group" required="true" label="Accept or Decline" name="accept-or-decline"> <option label="I accept travel insurance, please provide quotes of the above." value="i-accept-travel-insurance-please-provide-quotes-of-the-above">I accept travel insurance, please provide quotes of the above.</option> <option label="I decline travel insurance, or I will insure my trip on my own " value="i-decline-travel-insurance-or-i-will-insure-my-trip-on-my-own-">I decline travel insurance, or I will insure my trip on my own </option> </field> </fields> </form-template> </body> </html>
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