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.
1./Name as it appears on your passport
*
First Name
Middle Name
Last Name
2./Name as it appears on your passport
First Name
Middle Name
Last Name
Departure Date
-
Month
-
Day
Year
Date
Email Address
*
example@example.com
Travel Advisors Name:
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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.
*
Accept Cancellation Insurance
Decline Cancellation Insurance
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.
*
Accept Medical Insurance
Decline Medical Insurance
Signature
*
Date
-
Month
-
Day
Year
Date
Submit Waiver
Submit Waiver
Should be Empty: