Share your information with Empeiria Escapes

Empeiria Escapes

<html>
  <body>
<form-template>
  <fields><field type="text" subtype="text" required="true" label="First name" className="form-control" name="first-name"></field><field type="text" subtype="text" required="true" label="Last name" className="form-control" name="last-name"></field><field type="text" subtype="text" required="true" label="Email" className="form-control" name="email"></field>
    <field type="header" subtype="h2" label="Travel Insurance"/>
    <field type="paragraph" subtype="p" label="By signing below, I understand that declining travel insurance could result in the loss of my travel cost and/or require more money to correct the situation. I also acknowledge that without insurance, there may be no way to recoup any losses, costs or expenses incurred."/>
    <field type="header" subtype="h1" label="  "/>
    <field type="radio-group" label="Please choose:" name="please-choose">
      <option value="accept" label="I ACCEPT Travel Insurance.">I ACCEPT Travel Insurance.</option>
      <option value="decline" label="I DECLINE Travel Insurance. I understand that this could result in the loss of ALL of my travel costs.">I DECLINE Travel Insurance. I understand that this could result in the loss of ALL of my travel costs.</option>
    </field>
  </fields>
</form-template>
</body>
</html>

Click to sign