Travel Insurance Registration Form

Use the form below to purchase travel insurance.

Your purchase is only confirmed after we have received your payment and sent you a confirmation email.

Refer to your invoice or any information received from us for balances and payment due dates. For payment related questions please contact us at 410-497-7105 or at travel@bellesabound.com

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Booking #*
Number of Passengers*
Please select the number of passengers in your room.
Primary Passenger
The names printed on this registration form must match exactly the first, middle and last names in each passport.
Prefix*
Name*
Suffix
Date of Birth*
Month
Day
Year
Email*
Second Passenger
The names printed on this registration form must match exactly the first, middle and last names in each passport.
Prefix*
Name*
Suffix
Date of Birth*
Month
Day
Year
Email*
Third Passenger
The names printed on this registration form must match exactly the first, middle and last names in each passport.
Prefix*
Name*
Suffix
Date of Birth*
Month
Day
Year
Email*
Fourth Passenger
The names printed on this registration form must match exactly the first, middle and last names in each passport.
Prefix*
Name*
Suffix
Date of Birth*
Month
Day
Year
Email*
Travel Insurance
Please refer to your invoice or other information received from us for the cost of travel insurance. All rates are per person.
Insurance Plan*
Please select the travel insurance plan type you wish to pourchase.
Additional Information
Please add any optional information to explain your registration.
Payment Information
Please enter the amount to be charged on the card.
Amount*
Enter amount quoted. Do not include the dollar sign. (For example: 250.00)
Name on Credit Card*
Credit Card Type*
Visa Card Number*
MasterCard Number*
Discover Card Number*
American Express Card Number*
Expiration Month*
Expiration Year*
Security Code*
Billing Information
Address*
Street Address City State ZIP Code
Mobile Phone*
I hereby authorize Belles à Bound to charge my credit card for the amount above to make a one-time payment toward my outstanding balance for the booking above.*
Please enter your name. This will serve as your electronic signature - the equivalent to signing your name on a printed credit card authorization slip.
Date*
MM slash DD slash YYYY
Purchase Agreement
When you click the button to complete checkout on our website, or elect to purchase insurance and then complete checkout on our partner’s website, you are submitting a request to purchase a plan. This request is considered an offer by you. Your offer may be declined, or your plan may be cancelled or voided as if it were never in effect, if providing cover, benefit, or services under the plan, or the underlying business or activity, would (1) violate any applicable law or regulation, including without limitation any economic or trade sanction or embargo; or (2) be provided within, or otherwise related to, any country subject to comprehensive economic and/or trade sanction or embargo in the United States. By submitting this request for coverage, you acknowledge, understand, agree, and certify the following:

1. All information you have provided is accurate to the best of your knowledge and that, by selecting the button to complete your purchase, you are agreeing to pay the amount displayed as the total price with the credit card number provided. You are the owner and rightful user of the credit card used in this transaction. You further acknowledge, understand, and agree that plans purchased with intentionally inaccurate/fraudulent information will be considered void and that you may be subject to legal action as a result of such information.

2. You and all named insureds on your policy are U.S. residents and have obtained, or will have obtained prior to your scheduled departure date, and will maintain throughout your insured trip, all proper documentation, vaccinations, medical equipment/provisions, government licenses/authorizations/permits (including without limitation any required passports, visas, OFAC licensures, etc.), and any other prerequisite to travel that is required or otherwise necessary for your trip. You acknowledge, understand, and agree that your failure to obtain any of the above may not be covered under your plan, or may make you ineligible for coverage and/or assistance services under your plan. Additionally, you acknowledge, understand, and agree that all coverage and assistance services are subject to applicable law.

3. The policy you are purchasing is a named perils insurance policy, and it only covers the specific situations, events, and losses described in the policy and only under the conditions described in the policy.

4. Our plans include insurance benefits and assistance services, and the plan charge includes the price for insurance benefits and assistance services. Plans are offered and sold only as a single pay, single term, indivisible package of benefits and services for the purpose of covering risks associated with a trip or event/activity. If you purchase a third party’s trip cancellation fee waiver with your plan, the price for that trip cancellation fee waiver is included in the total amount charged for the plan. However, you can purchase the trip cancellation fee waiver separately from the third party, or you can purchase the plan without the trip cancellation fee waiver included. For more information, call us at 800-284-8300.

5. No coverage is available under the policy for any loss resulting directly or indirectly from any loss, condition, or event that was known, foreseeable, intended, or expected when your policy was purchased. This includes but is not limited to any cause of loss, condition, or event that, at or before the time the policy was purchased, was named or otherwise identified by (i) a Coverage Alert; or (ii) the National Oceanic and Atmospheric Administration (NOAA) or other entity that names or identifies meteorological or geological storms or events. When you purchase or modify coverage on a plan, you represent that you are not aware of any loss or claim already incurred or to be incurred for which you will seek coverage.

6. Since your satisfaction is our priority, we are pleased to provide you 15 days (or more, depending on your state of residence) to review your plan. If, during this period, you are not completely satisfied for any reason, you may cancel your plan and receive a full refund of the plan price. After this period, the plan price is nonrefundable. Please note, no refund is available if the trip has started, a claim has been filed, or the policy has ended. See your plan for details.

7. You consent to the processing of your personal data in accordance with our privacy policy.

8. We may employ automation and technology powered by systems which may be considered artificial intelligence systems under certain laws to market, provide, and improve our services.

9. Unless you chose to receive them by US Postal Service at the time of purchase, by purchasing your policy, you consent to receive all notices and documents from us electronically. They will be sent to the email address provided at the time of purchase. You may opt to receive notices and documents from us by mail at any time. If you do not wish to receive notices and documents electronically, or wish to later update your preference about the receipt of electronic notices and documents, email us at customerservice@allianzassistance.com. Please include your name, policy number, and a statement that “Only contact me by mail” (or something similar). You can also let us know by phone at 800-284-8300 or by mail to:

Allianz Global Assistance
ATTN: Customer Service – Only contact me by mail
9950 Mayland Drive
Richmond, VA 23233

Plans are subject to terms, conditions, and exclusions (including for pre-existing medical conditions, unless your plan includes a waiver of that exclusion and conditions for that waiver are met). Specific benefits and limits of coverage vary depending on the plan purchased. For a complete description of the coverage and specific benefit limits offered under your plan, carefully review your plan documents. Plans are available to U.S. residents only. All plans not available in all states. Contact AGA Service Company at plandetailsus@allianz.com for more information. Insurance benefits are underwritten, depending on your state of residence and product purchased, by: BCS Insurance Company (OH), Administrative Office: 2 Mid America Plaza, Suite 200, Oakbrook Terrace, IL 60181, rated “A” (Excellent) by A.M. Best Co., under BCS Form No. 52.201 series, 52.401 series; or Jefferson Insurance Company (NY), Administrative Office: 9950 Mayland Drive, Richmond, VA 23233, rated “A+” (Superior) by A.M. Best Co., under Jefferson Form Nos. 101-P series, 101-C series, 105-P series, 105-C series, 107-P series. Allianz Partners is a mark of AGA Service Company d/b/a Allianz Partners or its affiliates. AGA Service Company is the licensed producer and administrator of this plan and is an affiliate of Jefferson Insurance Company. The insured shall not receive any special benefit or advantage because of the affiliation between AGA Service Company and Jefferson Insurance Company. Assistance services are administered through AGA Service Company. Consumer is responsible for charges incurred from outside vendors for assistance services. Contact AGA Service Company at 800-284-8300 or 9950 Mayland Drive, Richmond, VA 23233 or customerservice@allianzassistance.com. AGA Service Company is doing business as Allianz Partners Insurance Agency in Arkansas, California (License # 0B01400), and Hawaii.

Allianz Partners compensates its suppliers or agencies for allowing Allianz Partners to market or offer products to customers of the supplier or agency.

Insurance Products Only

PLEASE BE ADVISED: This plan contains insurance benefits (which may include disability and/or health insurance benefits) that only apply during the covered trip. This optional coverage may duplicate coverage already provided by your personal auto, home, renter’s, health, life, personal liability, or other insurance policy or source of coverage but may be subject to different restrictions. You should review the terms of this policy with your existing coverage. If you have any questions about your current coverage, call your insurer/health plan or insurance agent/broker. This insurance is not required to purchase any other products/services. Unless licensed, travel retailers and their employees may provide general information about the insurance, including a description of coverage and price, but are not qualified/authorized to answer technical questions about terms, benefits, exclusions, and conditions of the insurance or evaluate the adequacy of existing coverage.

Additionally:

California Residents: We are doing business in California as Allianz Partners Insurance Agency, License # 0B01400. California offers a toll-free consumer hotline at 1-800-927-4357.

Maryland Residents: The purchase of travel insurance would make the travel insurance coverage primary to any other duplicate or similar coverage. The Commissioner may be contacted to file a complaint at: Maryland Insurance Administration, ATTN: Consumer Complaint Investigation Property/Casualty, 200 St. Paul Place, Suite 2700, Baltimore, MD 21202.

New York Residents: The licensed producer represents the insurer for purposes of the sale. Compensation paid to the producer may depend on the policy selected, or the producer’s expenses, volume of business, or profitability. The purchaser may request and obtain information about the producer’s compensation, except as otherwise provided by law.

Collision Damage Insurance (CDI) Only:

PLEASE BE ADVISED: Coverage is not available in all countries or for all cars. This coverage does not provide liability insurance or comply with any financial responsibility law, or any other law mandating motor vehicle coverage.

Texas Residents: Before deciding whether to purchase this insurance plan, you may wish to determine whether your own automobile insurance or credit card agreement provides you coverage for rental vehicle damage or loss and determine the amount of deductible under your own insurance coverage. The purchase of this insurance plan is not mandatory. This coverage is not all inclusive, which means it does not cover such things as personal injury, personal liability, or personal property. It does not cover you for damages to other vehicles or property. It does not cover you for any injury to any other party.

New York and Texas Residents: CDI coverage is only available when purchased as a separate policy.
Complete Purchase*
- I have read the Purchase Agreement.
Booking Terms & Conditions
Terms & Conditions Acceptance*
Booking Terms and Conditions
- By checking this box, I certify that I have read and understand the terms and conditions of my booking and that all information provided above is verified to be correct.

If you have trouble submitting your registration or have a question, please call 410-497-7105 during business hours Monday – Friday, 9:00 AM-7:00 PM Eastern Standard Time or email us directly at travel@bellesabound.com.

Travel Insurance Registration Form

Use the form below to purchase travel insurance.

Primary Passenger

Second Passenger

Third Passenger

Fourth Passenger

Travel Insurance

Payment Information

Billing Information

Purchase Agreement

Insurance Products Only

Booking Terms & Conditions