Travel Insurance Waiver

Travel Insurance Waiver
Departure *

Month Day Year
Date
Return *

Month Day Year
Date
Trip Description *
Europe Trip, Cruise, National Parks Tour (include names of cruise/tour vendors if applicable)
Total Trip Cost *
I decline the offer to purchase travel protection / trip insurance. I understand that I am solely responsible for any cancellation penalties and out-of-pocket expenses incurred. I will also make my own separate travel, medical and any other provisions in the event of an emergency while I am traveling. I also understand that I am not protected from loss in the event of any travel vendor, travel supplier or any travel-related operator default. This waiver confirms that I voluntarily decline travel insurance and travel protection insurance for the trip described above. I understand I am solely liable for all airline fees, supplier fees, and agency fees that may apply, and I hereby release LXR Travel, LLC, and its affilate Travel Experts Inc., a Virtuoso member, from any and all liability related to the trip described above.
List of Travelers that also decline Travel Insurance *
I have read this document. I understand this document and all consequences resulting from my decision to purchase or decline trip protection and trip insurance.
Name *

First Name Middle Name Last Name Suffix
Signature *

Use your mouse or touchscreen to sign in this box Clear
Date *

Month Day Year
Date
Email *
example@example.com
Should be Empty: