Travel Protection Waiver

Travel Protection Waiver
I have been offered and advised of Travel Protection options with a fee of [$136 pp] by my travel agent, Darric D. Coleman with What's Your Adventure?, LLC.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Would you like to purchase Travel Protection?*
If I choose not to purchase Travel Protection, I am aware in the event of an emergency, I am responsible to make my own provision. *
If no, do you have your own travel insurance?*
If you do not purchase or have your own Travel Protection, why would you not protect your investment? *
Departure*

MonthDayYear
Date
Return*

MonthDayYear
Date
Booking/Confirmation#*
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 the Burns, and its affilate Archer Travel from any and all liability related to the trip described above.
List of Travelers in my cabin 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.
Date*

MonthDayYear
Date
Signature*

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