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InsureMyTrip for Education Broker Enrollment Form

Agency Information:
Agency Contacts:
Primary Contact: *This question is required.
Secondary Contact: *This question is required.
Please provide the educational institutions that you are affiliated with:
Insurance License Information:

Please provide a copy of your home state Property and Casualty and/or Life and Health licenses and a list of any other non-resident insurance licenses held. License copies should be emailed to Brant McAleer at bmcaleer@insuremytrip.com, or faxed to 401-921-4528, or mailed to InsureMyTrip for Education, 100 Commerce Drive, Warwick RI 02886.