Travel Insurance Waiver

Travel Insurance Waiver
I have been offered and advised of travel protection / trip insurance options and fees by my travel agent, Heather Cook.
List price of insurance/Provider
*Example: Carnival Vacation Protection, Aliianz, AIG, etc
Do you have your own travel insurance?
If yes, List Travel insurance and policy number
If No, Reason for Decline of insurance.
Departure

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Return

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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 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
2 digit month, 2 digit day, 4 digit yearDate
Signature
Should be Empty: