Email AddressI decline to purchase the following travel insurance plan that my travel agent has offered and explained to me: *Trip InsuranceI, the undersigned, will not hold my travel agent or travel agency responsible for any expenses incurred from any sources as a result of:1. My refusal to purchase travel insurance at the time of initial deposit and for the full amount and duration of the trip.2. Any additional single supplement costs if my traveling companion is unable to travel and I still choose to travel.3. If insurance is not purchased at the time of the initial trip deposit, any additional costs such as: (pls select all boxes) *Increase in premiumChange in medical conditionIncreased supplier penaltiesFirst Name *Last Name *Type your complete name as confirmation *Date of SignatureTravel Agent's Name *Date of TravelDate of ReturnSend Message
