Travel Insurance Form

Travel Insurance Form

This is a form where clients indicate whether they would like travel insurance or not. This travel insurance form sample contains descriptions about the travel insurance. Also, this travel insurance template contains name, email, phone number, address, signature, departure date. Form Preview
  • Travel Insurance Form

  • By law I am required to offer you travel insurance.  For this reason I require that all of my clients complete, sign and submit this Travel Insurance Form indicating that you have been offered travel insurance, and should you chose not to purchase travel insurance you accept all responsibility.


  • Emergencies can happen when you least expect it.  I highly recommend that you protect your vacation with a travel insurance policy.  The cruise lines, airlines, hotels and tour operators all charge high penalties for cancellation, ranging from the full deposit to no refund at all.  Another important fact to keep in mind is that that most health insurance policies will not cover you when you are out of the country.  Your Travel Insurance will protect you in the following areas:


    Trip Cancellation

    Trip Delay

    Trip Interruption

    Missed Connection

    Baggage Loss, Theft or Damage

    Baggage Delay

    Emergency Medical and Dental Expenses

    Emergency Medical Transportation

    24/7 Hotline Assistance



    Please also note that in order for you to benefit from pre-existing coverage your policy must be purchased before final payment. (this is the case with Allianz, and does not apply to all of our suppliers' policies).  There is no added cost to the policy for pre-existing coverage.

    It is also important to understand that you do NOT have coverage until you have an active policy!  Pre-existing coverage will not apply to world events such as strikes, natural disasters, terrorism etc. 

    Please understand that I am not a registered insurance agent, and can not legally provide specific advice or information regarding insurance.   For information, please feel free to contact Allianz Insurance Company at 866-840-0837. 

    For your benefit, I have acquired a quote for travel insurance for your vacation from Allianz Insurance Company.  Your quote will be sent in a separate e-mail.

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  • If you would like to purchase Travel Insurance, please complete the Credit Card Authorization form by going to the following link:

  • I have been advised of, and understand the benefits of Travel Protection Insurance.  I understand that I do not have any coverage until 24 hours after this form has been signed and submitted.

    Should I decline this protection, I understand that I will assume all financial responsibility for any expenses incurred as a result of being unable to travel, or travel disrupted for any reason as well as any medical expenses.  I also understand that I must purchase Travel Insurance immediately to obtain maximum coverage,  in order to be covered for any pre-existiing conditions travel insurance must be purchased prior to final payment has been made, and it must cover full cost of all non-refundable trip arrangements. 

    Note:  Allianz will refund your premium if you cancel your insurance within 10 days of purchase, and have not filed a claim or departed on your trip.  

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  • Please use your mouse, stylus or finger to sign below.  Thank you! 

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  • Please understand that your booking can not be processed before you have completed and submitted this form.

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