Travel Insurance Waiver Form
Please carefully read the following sections to understand the implications of waiving your travel insurance coverage. Your acknowledgment and signature are required to proceed.
Name as it appears on your passport
*
First Name
Middle Name
Last Name
Name as it appears on your passport
First Name
Middle Name
Last Name
Email Address
*
example@example.com
Travel Advisors Name:
*
Phone Number
*
Please enter a valid phone number.
I acknowledge and choose to decline Out of Province Travel Medical Insurance offered to me by my travel agent ,through Northstar Travel. By signing , I agree that I will not hold Northstar Travel responsible for any expenses incurred as a result of my refusal to purchase travel insurance offered by Northstar Travel & Associates.
*
I agree
I acknowledge and choose to decline Cancellation Travel insurance offered to me by my travel agent ,through Northstar Travel. By signing , I agree that I will not hold Northstar Travel responsible for any expenses incurred as a result of my refusal to purchase travel insurance offered by Northstar Travel & Associates.
*
I agree
Signature
*
Date
-
Month
-
Day
Year
Date
Submit Waiver
Submit Waiver
Should be Empty: