Patriot Travel

Applicant Information

US DestinationUS Destination

If your trip includes the US or any US territory, select Yes

Date of Birth

Applicant Date of Birth

Coverage Dates

Start Date

Coverage Start Date

Date that coverage should begin. This date cannot be more than 6 months from today.

End Date

Coverage End Date

This date cannot be more than 12 months from the date coverage begins.

Yes, I need dependent coverage.

Dependent Coverage - Dates of Birth

SpouseSpouse

Only specify the spouse date of birth if this person is to be covered.

SpouseSpouse

Only specify the spouse date of birth if this person is to be covered.

Child 1Child 1

Only specify the date of birth if this person is to be covered.

Child 1Child 1

Only specify the date of birth if this person is to be covered.

Child 2Child 2

Only specify the date of birth if this person is to be covered.

Child 2Child 2

Only specify the date of birth if this person is to be covered.

Add more dependents

Coverage Options

Adventure SportsAdventure Sports

The Adventure Sports Rider is available on both Patriot plans for those up to the age of 65. Certain adventure sports are covered (to the maximum amounts listed on the Benefits page) as long as they are engaged solely for leisure, recreation, or entertainment purposes. This is only a summary of Adventure Sports coverage and exclusions, please see Exclusion 8 for the full list of covered activities, exclusions and more information

Need Assistance?

Toll Free: +1 (877) 758-4391

Direct: +1 (904) 758-4391

Fax: +1 (904) 212-0412

Email: Email

Twitter: @intl_insurance