Travel Insurance Waiver Form

Travel Insurance Waiver Form
Please read the following information carefully and sign below if you wish to decline travel insurance coverage for your upcoming trip.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Do you have your own travel insurance?
If yes, List Travel insurance and policy number
Do you wish to decline travel insurance?
Departure

MonthDayYear
Date
Return

MonthDayYear
Date
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 Traveling with Paradiso Adventures, and its affilate Archer Travel from any and all liability related to the trip described above.
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.
Date

MonthDayYear
Date
Signature

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