Travel Insurance Credit Card Authorization Form

TRAVEL PURCHASE AUTHORIZATION For Non-Website Purchases
To complete your transaction and confirm your Allianz travel insurance plan, your signature on this authorization is required. This form is NOT required for electronic purchases you complete yourself on our website. Charges are payable ONLY to the agency or the hotel, insurance, resort, tour operator, cruise line or other travel supplier. Independent Travel Agents may not accept and process charges through any other account, or accept checks, cash or other forms of payment.

It’s very important that before purchasing, you carefully review and agree with Allianz’s purchase terms and disclosures and plan and pricing details. By completing this form, you authorize us to charge your card for your Allianz travel insurance policy, and you affirm that you have reviewed the terms, disclosures and plan and pricing details.

Allianz offers a satisfaction guarantee, meaning if you are not completely satisfied, you have 15 days (or more, depending on state of residence) to request a refund, provided you haven’t started your trip or initiated a claim. Premiums are non-refundable after this period.

Client Name*

First NameLast Name

Email*

example@example.com

Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Charge Authorization*

I have ACCEPTED and authorize the purchase of an Allianz travel insurance plan, and I am aware the insurance premium is not refundable beyond the 15-day satisfaction guarantee offered by Allianz. I attest that I have reviewed and agree with the Allianz purchase terms and disclosures and pricing details, which are linked above.

Travel Insurance Plan (Select One)*

Allianz Annual Premier Plan $2,000 (cost is $485 per year)Allianz Annual Premier Plan $5K (cost is $715 per year)Allianz Annual Premier Plan $10K (cost is $1,050 per year)Allianz Annual Premier Plan $15K (cost is $1,530 per year)Other

Total Amount Authorized*

Please provide the last four digits of the credit card you authorize us to charge (For your protection, we will collect the full number from you over the phone).*

I hereby authorize Melissa Newman Consulting and Creatives and its booking partners or the travel supplier that my booking is valid to charge my credit card for travel reservation and/or travel insurance policy and confirm that the information for the credit card and billing address is complete and accurate.

Signature

Credit Card Authorization for Travel Insurance