EmailMe Form - TRAVEL INSURANCE WAIVER

Name

First Middle Last

Travelers Departure Date

MM / DD / YYYY

Travelers Return Date

MM / DD / YYYY

Description of Trip

Please check one the following

I ACCEPT TRAVEL INSURANCE COVERAGE

I DECLINE TRAVEL INSURANCE COVERAGE

I AM UNDECIDED (MUST PURCHASE WITHIN 14 DAYS OF INITIAL DEPOSIT TO RECEIVE COVERAGE

Today's Date

MM / DD / YYYY

This form was submitted by:

First Middle Last

Signature - use your finger or mouse to sign.