Client Name:

File:

Email:

I have been advised that the following travel insurance is available and understand that by signing below, I decline and waive the following insurance coverages for myself and everyone confirmed in my travel reservation:

Emergency Hospital & Medical

Rental Car Collision Damage Protection

Trip Cancellation & Interruption

Baggage

Accidental Death & Dismemberment

Flight Accident

I acknowledge and accept that any expenses incurred, while not covered by a travel insurance policy, will be my own financial responsibility. My Advisor has no responsibility for these possible expenses.

Note: all items must be checked off prior to submitting.