BC Vacations Travel Insurance Request Form

Landsman Insurance Services, is a trusted expert in travel insurance. You get guidance from a team with deep underwriting experience and access to multiple top-rated carriers. When you work with Landsman Insurance Services you'll receive clear options built around your trip, and your budget. No guesswork. No one-size-fits-all plans. Please fill out the form to get tailored coverage options designed to protect your investment and your peace of mind.
Travel Insurance Quote Request Form
Name of Person Completing Form if different than Traveler 1

First NameLast Name
Email of Person Completing Form if different than Traveler 1
example@example.com
Phone Number of person completing form if different than Traveler 1
Please enter a valid phone number.Format: (000) 000-0000.
Affiliate Agency (if Applicable)
Name of Traveler 1

First NameLast Name
Email of Traveler 1
example@example.com
Traveler 1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Traveler 1 Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of birth of Traveler 1

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Trip Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Trip End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of first Trip Deposit

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Total Trip Cost Traveler 1
Types of Expenses to Insure
Who will be paying for the insurance for Traveler 1?
Please describe the trip and list all states, and international countries being visited during travel. If certain travelers are only going to certain destinations, but not all please indicate that here.
Please provide any other information you'd like to share here.
If you'd like to upload a copy of your itinerary you may do so here.

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Traveler 2 Name

First NameLast Name
Is Traveler 2's Address the same as Traveler 1?
If no to above please indicate address for Travel 2 here.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Traveler 2 Trip Cost
Traveler 2 DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Travel Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Travel End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Traveler 2 Email
example@example.com
Traveler 2 Types of Expenses to Insure
Traveler 2 Relation to Traveler 1
Who will be paying for the insurance for Traveler 2?
Traveler 3 Name

First NameLast Name
Is Traveler 3's Address the same as Traveler 1?
If no to above please indicate address for Travel 3 here.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Traveler 3 Trip Cost
Traveler 3 DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Travel Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Travel End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Traveler 3 Email (If you want to use the same email for all travelers leave this blank)
example@example.com
Traveler 3 Relation to Traveler 1
Traveler 3 Types of Expenses to Insure
Who will be paying for the insurance for Traveler 3?
Traveler 4 Name

First NameLast Name
Is Traveler 4's Address the same as Traveler 1?
If no to above please indicate address for Travel 4 here.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Traveler 4 Trip Cost
Traveler 4 DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Travel Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Travel End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Traveler 4 Email (If you want to use the same email for all travelers leave this blank)
example@example.com
Traveler 4 Relation to Traveler 1
Traveler 4 Types of Expenses to Insure
Who will be paying for the insurance for Traveler 4?
Traveler 5 Name

First NameLast Name
Is Traveler 5's Address the same as Traveler 1?
If no to above please indicate address for Travel 5 here.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Traveler 5 Trip Cost
Traveler 5 DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Travel Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Travel End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Traveler 5 Email (If you want to use the same email for all travelers leave this blank)
example@example.com
Traveler 5 Relation to Traveler 1
Traveler 5 Types of Expenses to Insure
Who will be paying for the insurance for Traveler 5?
Traveler 6 Name

First NameLast Name
Is Traveler 6's Address the same as Traveler 1?
If no to above please indicate address for Travel 6 here.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Traveler 6 Trip Cost
Traveler 6 Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Travel Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Travel End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Traveler 6 Relation to Traveler 1
Traveler 6 Types of Expenses to Insure
Who will be paying for the insurance for Traveler 6?
Traveler 7 Name

First NameLast Name
Is Traveler 7's Address the same as Traveler 1?
If no to above please indicate address for Travel 7 here.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Traveler 7 Trip Cost
Traveler 7 DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Travel Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Travel End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Traveler 7 Email (If you want to use the same email for all travelers leave this blank)
example@example.com
Traveler 7 Relation to Traveler 1
Traveler 7 Types of Expenses to Insure
Who will be paying for the insurance for Traveler 7?
Traveler 8 Name

First NameLast Name
Is Traveler 8's Address the same as Traveler 1?
If no to above please indicate address for Travel 8 here.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Traveler 8 Trip Cost
Traveler 8 DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Travel Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Travel End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Traveler 8 Email (If you want to use the same email for all travelers leave this blank)
example@example.com
Traveler 8 Relation to Traveler 1
Traveler 8 Types of Expenses to Insure
Who will be paying for the insurance for Traveler 8?
Traveler 9

First NameLast Name
Is Traveler 9's Address the same as Traveler 1?
If no to above please indicate address for Travel 9 here.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Traveler 9 Trip Cost
Traveler 9 Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Travel Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Travel End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Traveler 9 Email (If you want to use the same email for all travelers leave this blank)
example@example.com
Traveler 9 Relation to Traveler 1
Traveler 9 Types of Expenses to Insure
Who will be paying for the insurance for Traveler 9?
Traveler 10

First NameLast Name
Is Traveler 10's Address the same as Traveler 1?
If no to above please indicate address for Travel 10 here.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Traveler 10 Trip Cost
Traveler 10 Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Travel Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Travel End Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Traveler 10 Email (If you want to use the same email for all travelers leave this blank)
example@example.com
Traveler 10 Relation to Traveler 1
Traveler 10 Types of Expenses to Insure
Who will be paying for the insurance for Traveler 10?
Should be Empty:

Travel Insurance Quote Request Form