| Your Signature is REQUIRED. A hard copy of this form is available by clicking here if you prefer to submit your agreement by regular mail (you may also right-click and "save taget as..." in order to save the file to your computer). |
- Fields marked with * are required.
- The invoice number is a 5 digit number found in the upper left portion of your Clearwater Cruises invoice.
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Client Information -
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| * First Name: |
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* Last Name: |
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| * Invoice Number: |
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* Email Address: |
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Travel Insurance Choice -
Select your insurance option below. |
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Your best option:
Option 1: "I agreed to purchase Travel Insurance at or within 14 days of initial deposit . My travel protection begins immediately. By purchasing insurance within 14 days of deposit, and covering all nonrefundable trip costs I receive the added benefit of coverage for Existing Medical Conditions for myself, traveling partner, and immediate family members at no additional cost. I authorized my credit card to be charged for Allianz Travel Insurance.
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| Option 2: "I will purchase Travel Insurance after final payment but no later than 48 hours prior to scheduled departure. My travel protection begins when the insurance is paid for but I will NOT have the benefit of waiver for Existing Medical Conditions. I authorized my credit card to be charged for Allianz Travel Insurance at time of final payment as listed on my invoice. |
| Option 3: "No - I decline Allianz Travel Insurance coverage and accept the inherent risks and liabilities. The benefits have been explained, but by signing below I choose to decline Allianz Travel Insurance." |
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Emergency Contact -
In the event of an emergency we may need to contact a family member or friend for you. Please provide us with the name, address and phone number of the person you would like for us to contact on your behalf. |
| * (Emergency)Contact Name: |
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* (Emergency)Relation to You: |
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| * (Emergency)Address: |
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(Emergency)Apt / Suite: |
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| * (Emergency)Home Phone: |
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(Emergency)Work Phone: |
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| * (Emergency)City: |
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* (Emergency)State: |
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| * (Emergency)Zip: |
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Electronic Signature -
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| Paying by: Credit Card Check or Cash |
| By entering the following information and submitting this form I acknowledge that I have read and agree with the information on the Clearwater Cruises invoice #. I agree to pay those charges and I further agree to the terms and conditions provided with that invoice. |
| Insurance |
| Deposit |
| Final Payment –The charge will be processed to the same credit card when final payment is due. |
| * Last Four Digits of Card Number: |
| * Full Name as it Appears on Card: |
* Date: |
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