Insurance Declaration

Travel insurance is one of the most important considerations as you plan your vacation. Please read the information provided to you by your agent and make sure you understand it before completing the form below. As always, we're here to answer any questions you may have.

Name*
First Last
Phone*
Vendors for my trip include but may not be limited to:*
Email*
Travel Start Date*
Date Format: MM slash DD slash YYYY
Travel End Date*
Date Format: MM slash DD slash YYYY
Insurance Providers Offered to Me*
- Select All
- Allianz
- Travel Guard
- CCRA
- Other Insurer Known to Me
I, the individual specified above and recorded from this form, hereby verify that I have reviewed my travel itinerary for accuracy. I have been advised of all applicable fees with the vendor(s) associated with my trip which spans the dates indicated above and recorded from this form if I decide to change my travel plans. I understand that discounted fares and vacation packages may have restrictions and that changing any aspect of my travel may result in the payment of additional fees or other forms of loss. I have been offered travel insurance through the insurer indicated above and recorded from this form and understand if I choose not to purchase trip protection at this time, I may be able to purchase it until the final payment is due, but any pre-existing medical conditions will not be covered.
Insurance Choice*
- I do wish to purchase travel protection from the insurer indicated above and recorded on from this form and authorize my card to be charged today. I understand that if I choose to cancel my trip for fear of incident, quarantine or trip interruption due to an epidemic or pandemic insurance policies will not cover such losses.
- I do NOT wish to purchase travel protection. I waive all protection from the insurer(s) indicated above and recorded from this form and any assistance for cancellation or travel interruption.
Lead Passenger Name Authorized to Accept/Decline Insurance*
First Last
Signature of Lead Passenger Authorized to Accept/Decline Insurance*
By typing your name above, you agree to the use of electronic consent with the same binding authority as your own notarized signature.
Date*
Date Format: MM slash DD slash YYYY