TravelJoy

Sherrelle D. Russell

LC Scursion Travel

Travel Insurance Quote Request

Jan 1, 2025 to Jan 1, 2028

Vacation Protection

<html>
  <body>
    <form-template>&#13;
	<fields>&#13;
		<field type="header" subtype="h1" label="Welcome!!!!"/>&#13;
		<field type="paragraph" subtype="p" label="Thank you for considering us for your future vacation travel insurance! We are excited to assist you with your securing your vacation from a different level of protection for you and your family. To get started, please complete the inquiry form in which your quote will be provided within 24 hours of submitting your form.&amp;nbsp;"/>&#13;
		<field type="text" label="Prefix" name="prefix" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="First name" name="first-name" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Last name" name="last-name" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Email" name="email" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Phone number" name="phone-number" subtype="text" className="form-control"/>&#13;
		<field type="header" subtype="h1" label="Travel Information"/>&#13;
		<field type="date" required="true" label="Departure Date?" description="This just gives me a general idea of when you like to go; it can be changed later." name="starting-at" className="form-control"/>&#13;
		<field type="date" required="true" label="Return Date?" description="This just gives me a general idea of when you like to return; it can be changed later." name="ending-at" className="form-control"/>&#13;
		<field type="text" required="true" label="Total Vacation Cost:" description="Where will you be flying from?" name="departure-city" subtype="text" className="form-control"/>&#13;
		<field type="radio-group" required="true" label="How many adults?" name="how-many-adults" other="true">&#13;
			<option label="1" value="1">1</option>&#13;
			<option label="2" value="2">2</option>&#13;
			<option label="3" value="3">3</option>&#13;
		</field>&#13;
		<field type="text" label="If selected OTHERS,&amp;nbsp; how many?" name="number-of-travelers" subtype="text" className="form-control"/>&#13;
		<field type="radio-group" required="true" label="How many children?" name="how-many-children" other="true">&#13;
			<option label="1" value="1">1</option>&#13;
			<option label="2" value="2">2</option>&#13;
			<option label="3" value="3">3</option>&#13;
		</field>&#13;
		<field type="text" label="Provide Date of Birth for all Travelers" name="age-of-children" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Destination:" name="must-dos" subtype="text" className="form-control"/>&#13;
	</fields>&#13;
</form-template>
  </body>
</html>