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Insurance Waiver

Your travel advisor is obligated to offer you travel insurance. If you choose to waive the travel insurance that they have offered you, please complete the following form.

All fields marked with asterisk* are mandatory

Trip Information

Trip Name^*

Traveler 1 Name^*

Your name should read as stated in your passport

Birthdate^*

Traveler 2 Name^*

Your name should read as stated in your passport

Birthdate^*

Traveler 3 Name^*

Your name should read as stated in your passport

Birthdate^*

Traveler 4 Name^*

Your name should read as stated in your passport

Birthdate^*

Traveler 5 Name^*

Your name should read as stated in your passport

Birthdate^*

Traveler 2 Name^*

Your name should read as stated in your passport

Traveler 6 Name^*

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Contact Information

First Name^*

Address^*

Phone (day)^*

Last Name^*

City^*

Phone (night)

E-mail^*

Province/State^*

Postal Code^*

I decline to purchase any travel insurance plans that my travel agent has offered and explained to me. Date: Jan 19, 2021

You must decline travel insurance to submit this form.