Please fill out this form as completely as possible so that all of your family members are covered by this flight insurance. Read all of the information by scrolling down to the bottom and Initial, Date, and be sure to check the box, before submitting your form.

MEMBER ENROLLMENT INFO

Your Full Name (required)

DOB (required)

Spouse/Domestic Partner Full Name

DOB

Address (required)

City (required)

State (required)

Zip (required)

Phone (required)

Your Email (required)

Additional Household Members:

Includes any dependents claimed on your tax return and elderly or disabled family members living in the same household.

HouseHold Member 1 Full Name

DOB

Relationship

HouseHold Member 2 Full Name

DOB

Relationship

HouseHold Member 3 Full Name

DOB

Relationship

HouseHold Member 4 Full Name

DOB

Relationship

HouseHold Member 5 Full Name

DOB

Relationship

HouseHold Member 6 Full Name

Relationship

DOB

DISCOUNT GROUP MEMBERSHIP RATE

$75 (+ $3 CC convenience fee, if paid online) - 1 Year. Renewals are due in Jan. of each year, emails will be sent out, and may be followed up via phone.

Current LFN Member Y/N :NoYes

LFN ID Number (If Known)

AGREEMENT AND CONSENT

(We/I) Agree to the above conditions

(Check indicates agreement - Required) Check for acceptance

Initials (in lieu of Signature) Date