Enrollment

"*" indicates required fields

Member Details

Step 1 of 5

Name*

First Name * Last Name *

Member ID #

Email Address*

Includes $200,000 Travel Accident Insurance. Provide required member details and choose whether or not you’d like to also cover your spouse.

Member Date of Birth*
Month
Day
Year

Member Gender*

Male

Female

Coverage Amount

Add Spouse

Add Spouse

Spouse coverage will be equal to member's coverage amount.

Spouse Name*
Spouse First Name * Spouse Last Name *

Spouse Date of Birth*
Month
Day
Year

Spouse Gender*

Male

Female

The rates quoted are based on age as of today. Your premium shown on your bill will reflect your age as of your effective date and may differ from above.

Payment Method

Bank Transfer
Bank Transfer (ACH)

Chasehps Payment
Credit card payment via Chasehps secure servers

-- Total Monthly Cost Including Fees

Travel Accident Protection

Emergency & Accident

Property & Liability

Personal Insurance