Travel Insurance Form

Travel Insurance Form
By law I am required to offer you travel insurance. For this reason I require that all of my clients complete, sign and submit this Travel Insurance Form indicating that you have been offered travel insurance, and should you chose not to purchase travel insurance you accept all responsibility.
Emergencies can happen when you least expect it. I highly recommend that you protect your vacation with a travel insurance policy. The cruise lines, airlines, hotels and tour operators all charge high penalties for cancellation, ranging from the full deposit to no refund at all. Another important fact to keep in mind is that that most health insurance policies will not cover you when you are out of the country. Your Travel Insurance will protect you in the following areas:

Trip Cancellation

Trip Delay

Trip Interruption

Missed Connection

Baggage Loss, Theft or Damage

Baggage Delay

Emergency Medical and Dental Expenses

Emergency Medical Transportation

24/7 Hotline Assistance

Please also note that in order for you to benefit from pre-existing coverage your policy must be purchased before final payment. There is no added cost to the policy for pre-existing coverage.

It is also important to understand that you do NOT have coverage until you have an active policy! Pre-existing coverage will not apply to world events such as strikes, natural disasters, terrorism etc.

Please understand that I am not a registered insurance agent, and can not legally provide specific advice or information regarding insurance. For information, please feel free to contact Allianz Insurance Company at 1-866-884-3556.

For your benefit, I have acquired a quote for travel insurance for your vacation from Allianz Travel. Your quote will be sent in a separate e-mail.
Please sign this acknowledgement to accept or decline the Travel Insurance that is being offered to you.*

YES, I want to purchase Travel Insurance at this time. I will have coverage for pre-existing conditions. There are no added cost for this coverage.YES, but not at this time. Please understand that you are not covered until your policy has been purchased.NO, I do not want to purchase Travel Insurance, and assume all responsibility.
Full Name

First NameLast Name
E-mail
example@example.com
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
I have been advised of, and understand the benefits of Travel Protection Insurance.

I understand that I do not have any coverage until 24 hours after this form has been signed and submitted.

Should I decline this protection, I understand that I will assume all financial responsibility for any expenses incurred as a result of being unable to travel, or travel disrupted for any reason as well as any medical expenses. I also understand that I must purchase Travel Insurance immediately to obtain maximum coverage, in order to be covered for any pre-existiing conditions travel insurance must be purchased prior to final payment has been made, and it must cover full cost of all non-refundable trip arrangements.
Please use your mouse, stylus or finger to sign below. Thank you!
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Date:

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Please complete if requesting insurance:
Date of Birth

MonthDayYear
Date
Departure Date

MonthDayYear
Date
Return Date

MonthDayYear
Date
Deposit Date

MonthDayYear
Date
Entire Trip Cost $
Additional person

First NameLast Name
Date of Birth

MonthDayYear
Date

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Date
Please understand that your booking can not be processed before you have completed and submitted this form.
Should be Empty:

Travel Insurance Form

Please complete if requesting insurance: