Share your information with Christine Wilson

Christine Wilson

Envoyage Travel TICO #50016384 | CPBC #2790

<html>
  <body>
    <form-template>&#13;
	<fields>&#13;
		<field type="header" subtype="h1" label="Travel Insurance Price Quote"/>&#13;
		<field type="paragraph" subtype="p" label="Fill out this form for a no obligation travel insurance quote. Please answer each question as best you can. Every province has their own regulations when it comes to insurance so we have to know where you live to be able to quote correctly. "/>&#13;
		<field type="header" subtype="h2" label="Travellers"/>&#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="date" required="true" label="Birthdate" name="birthdate" className="form-control"/>&#13;
		<field type="text" required="true" label="Phone number" name="phone-number" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Email" name="email" subtype="text" className="form-control"/>&#13;
		<field type="textarea" label="Names of additional travellers and dates of birth" name="names-of-additional-travellers-and-dates-of-birth" className="form-control"/>&#13;
		<field type="header" subtype="h2" label="Address"/>&#13;
		<field type="text" label="Line 1" name="address-line-1" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Line 2" name="address-line-2" subtype="text" className="form-control"/>&#13;
		<field type="text" label="City" name="address-city" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Province" name="address-state" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Postal Code" name="address-zip" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Country" name="address-country" subtype="text" className="form-control"/>&#13;
		<field type="header" subtype="h2" label="Insurance questions"/>&#13;
		<field type="radio-group" label="Do all travellers live at the same address?" name="do-all-travellers-live-at-the-same-address">&#13;
			<option label="Yes" value="yes">Yes</option>&#13;
			<option label="No" value="no">No</option>&#13;
		</field>&#13;
		<field type="checkbox-group" required="true" label="What type of coverage are you looking for? (check all that apply)" name="what-type-of-coverage-are-you-looking-for-check-all-that-apply">&#13;
			<option label="Comprehensive Single-trip Plan (medical, cancellation, interruption)" value="comprehensive-singletrip-plan-medical-cancellation-interruption">Comprehensive Single-trip Plan (medical, cancellation, interruption)</option>&#13;
			<option label="Emergency Hospital &amp; Medical" value="emergency-hospital-medical">Emergency Hospital &amp; Medical</option>&#13;
			<option label="Trip Cancellation &amp; Interruption" value="trip-cancellation-interruption">Trip Cancellation &amp; Interruption</option>&#13;
			<option label="Comprehensive Multi-Trip Plan" value="comprehensive-multitrip-plan">Comprehensive Multi-Trip Plan</option>&#13;
			<option label="Emergency Hospital &amp; Medical Multi-Trip Plan" value="emergency-hospital-medical-multitrip-plan">Emergency Hospital &amp; Medical Multi-Trip Plan</option>&#13;
		</field>&#13;
		<field type="radio-group" required="true" label="Are all insureds covered for medical under a valid government health insurance plan?" name="are-all-insureds-covered-for-medical-under-a-valid-government-health-insurance-plan">&#13;
			<option label="Yes" value="yes">Yes</option>&#13;
			<option label="No" value="no">No</option>&#13;
			<option label="Unsure" value="unsure">Unsure</option>&#13;
		</field>&#13;
		<field type="date" required="true" label="Start date of travel" name="start-date-of-travel" className="form-control"/>&#13;
		<field type="date" required="true" label="Return date of travel (date you are returning to Canada)" name="return-date-of-travel-date-you-are-returning-to-canada" className="form-control"/>&#13;
		<field type="text" required="true" label="Where are you traveling to? " name="where-are-you-traveling-to-" subtype="text" className="form-control"/>&#13;
		<field type="text" label="What is the total value of the trip you are insuring? (leave blank if you don&#39;t want cancellation insurance) " name="what-is-the-total-value-of-the-trip-you-are-insuring-leave-blank-if-you-dont-want-cancellation-insurance-" subtype="text" className="form-control"/>&#13;
		<field type="checkbox-group" required="true" label="Travel Agent you are working with." name="travel-agent-you-are-working-with" other="true">&#13;
			<option label="Christine Wilson" value="christine-wilson">Christine Wilson</option>&#13;
			<option label="Scott Rayner" value="scott-rayner">Scott Rayner</option>&#13;
			<option label="Jordan Wilson" value="jordan-wilson">Jordan Wilson</option>&#13;
			<option label="Dan's Dive Shop" value="dans-dive-shop">Dan's Dive Shop</option>&#13;
			<option label="Angie Anderson" value="angie-anderson">Angie Anderson</option>&#13;
		</field>&#13;
	</fields>&#13;
</form-template>
  </body>
</html>