Enrollment - The LIT

Name*

First Name * Last Name *

Member ID #

Department*

Email Address*

Address*

‎ ‎ City State Zipcode

Phone

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*

Member Gender*

Male

Female

Add Spouse

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

Spouse Name*

Spouse First Name * Spouse Last Name *

Spouse Date of Birth*

Spouse Gender*

Male

Female

Your Travel Accident plan automatically includes these valuable benefits:

Accident Hospital

$500-A-DAY CASH BENEFITS PAID for every day you’re treated as an inpatient in a hospital because of a covered travel accident. Benefits paid directly to you for up to 365 days.

Automatically included in your plan

Common Carrier

PLUS AN ADDITIONAL $200,000 CASH BENEFITS PAID FOR A TOTAL OF UP TO $400,000 to your beneficiary if you die in a covered accident as a fare-paying passenger on an airplane, taxi, bus, cruise ship, train or other common carrier

Automatically included in your plan

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.

As a member, I have read and accepted the .

Payment Method

Bank Transfer

Bank Transfer (ACH)

Chasehps Payment

Credit card payment via Chasehps secure servers

--Total Monthly Cost Including Fees

Travel Accident Protection

Your Travel Accident plan automatically includes these valuable benefits:

Accident Hospital

Common Carrier

Emergency & Accident

Property & Liability

Personal Insurance