EmailMe Form - Go! Travel... Getaways

Traveler's / Client's Name *

First Last

Email *

Travelers Names and Ages Times of Travel

Travel Departure Date
(Date Coverage will Start) *

MM / DD / YYYY

Travel Return Date
(Date Coverage will End) *

MM / DD / YYYY

Describe your vacation package inclusions:
Examples: All-Inclusive Resort, R/T Airfare, Rental Car, Hotel Stay, or Cruise for a family of 4 (some or all of these may apply) *

Please read and then check to indicate understanding of each of the following
(To be completed at the time of Initial Deposit and/or Payment): *

I have been ADIVISED of the cancelation penalties related to my purchase.

I UNDERSTAND that travel protection can protect me from possible loss of money due to supplier bankruptcy/default.

I also UNDERSTAND that Travel Protection can cover accidents, sickness and/or death.

I further UNDERSTAND that Travel Protection can cover baggage loss, medical expenses, and emergency air transportation costs.

Travel Protection Option *

I ACCEPT Travel Protection Coverage

I DECLINE Travel Protection Coverage

I AM UNDECIDED (I understand that I MUST purchase WITHIN 7 DAYS of initial deposit to receive coverage AND I will be required to submit another travel protection form at the time my decision is made.)

Form Submitted By: *

First Last

Electronic Signature *

I declare that the above information is true and accurate. (Minimum of 2 Characters required)

Date Signed *

MM / DD / YYYY

Signature - Please add physical signature if possible.

Clear