Insure Your Luxury Travel

Attention Agents:

The below form is required for each of your clients that have booked a trip (whether or not they express interest in purchasing the insurance at this time). This form is crucial to making sure that the commission is appointed to the correct agent. If you need to add a Top up/ Add on to the policy please continue to scroll down for the appropriate form.

All Tully agents are legally obligated to send a form to InsureYourLuxuryTravel.com whether or not your clients purchase or express interest to purchase insurance.

Lynette Rempel or Craig Robinson will notify you when the client purchases. If you have any questions feel free to email lynette@insureyourluxurytravel.com.

Primary Agent Name:*
Please select your name below.
Assistant Agent Name:*
Please select your name below.
Agent Email*
Notes to Lynette & Craig :
Please note if your client is not looking to purchase the insurance immediately. We will notate that information in our database and follow up when they are ready.
Traveler # 1 Information*
First Last
Date of Birth*
MM slash DD slash YYYY
Traveler # 2 Information
NOTE: If the travelers have different residence addresses, please fill out a separate quote form for each as they will need to purchase separate policies.
First Last
Date of Birth
MM slash DD slash YYYY
Traveler # 3 Information
NOTE: If the travelers have different residence addresses, please fill out a separate quote form for each as they will need to purchase separate policies.
First Last
Date of Birth
MM slash DD slash YYYY
Traveler # 4 Information
NOTE: If the travelers have different residence addresses, please fill out a separate quote form for each as they will need to purchase separate policies.
First Last
Date of Birth
MM slash DD slash YYYY
Traveler # 5 Information
NOTE: If the travelers have different residence addresses, please fill out a separate quote form for each as they will need to purchase separate policies.
First Last
Date of Birth
MM slash DD slash YYYY
Traveler # 6 Information
NOTE: If the travelers have different residence addresses, please fill out a separate quote form for each as they will need to purchase separate policies.
First Last
Date of Birth
If you have more than 6 travelers please enter additional traveler information at the end of the form.
MM slash DD slash YYYY
Relationship Status (if known)
Please let us know if these travlers are family members, married couple, or traveling companions. This helps us know how to address the clients in communications. Thank you.
Pre-Existing Conditions Known?*
If YES, please list the known condition in the comments section at the bottom of the form for all travelers.
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Primary Phone*
Secondary Phone
Traveler # 1 Trip Cost*
Traveler # 2 Trip Cost
Traveler # 3 Trip Cost
Traveler # 4 Trip Cost
Traveler # 5 Trip Cost
Traveler # 6 Trip Cost
Departure Date*
MM slash DD slash YYYY
Return Date*
MM slash DD slash YYYY
Deposit Date*
Date that the first deposit was put down
MM slash DD slash YYYY
Deposit Amount*
Amount to be Paid in Full*
Even if your client has not paid in full, please give us the total amount to be paid for the entire trip.
Final Payment Date*
MM slash DD slash YYYY
Future Cruise Credit?*
Does the client have a future cruise credit to use with this trip? Please answer.
- Yes - FCC was paid by the client/traveler (insurable)
- Yes- FCC was gifted to client/traveler (not insurable)
- No - No FCCs will be used for this trip
Travel Supplier*
Please let us know what travel supplier/tour operator/cruise line they are traveling with.
Traveler's Itinerary*
Please upload a copy of your client's full itinerary.
Max. file size: 64 MB.
Max. file size: 64 MB.
Max. file size: 64 MB.
Client's Preffered Contact Method
Additional Travelers Information
Please enter additional travelers full names and date of births above.
Pre-Existing Comments or Questions:
After filling out the form you will see a Confirmation page that says, "Your Form has Been Submitted!" If you do not see this confirmation notification the form did not go through. Thank you!
Email
This field is for validation purposes and should be left unchanged.

ADD – ON / Top Up Form:

Primary Agent Name*
First Last
Assistant Agent Name
First Last
Primary Agent Email*
Primary Traveler Name*
First Last
Primary Traveler Email
Primary Traveler Phone
Original Policy Purchase/Issue Date*
MM slash DD slash YYYY
Insurance Carrier*
Policy Number*
Destination
Original Trip Cost Per Person
Top-Up/ADD-ON Purchase Date
MM slash DD slash YYYY
Top-Up/Add On Amount per person
New Departure Date
MM slash DD slash YYYY

Please list the new departure date if it has changed from the original policy. If the departure date has not changed you may leave blank.
New Return Date
MM slash DD slash YYYY

Please list the new return date if it has changed from the original policy. If the departure date has not changed you may leave blank.
NEW or UPDATED Itinerary
Max. file size: 64 MB.
NEW or UPDATED Itinerary
Max. file size: 64 MB.
NEW or UPDATED Itinerary
Max. file size: 64 MB.
NOTES:
Please add any notes for Craig Robinson and his team regarding the Top-Up/Add-on

Lynette Rempel for
Craig Robinson
Insurance Consultants Int’l
1840 Deer Creek Rd #201
Monument, CO 80132

Phone: 719-428-4502

email: lynette@insureyourluxurytravel.com
websites: www.insureyourluxurytravel.com

Attention Agents:

ADD – ON / Top Up Form:

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