Share your information with Karla Bronaugh

Karla Bronaugh

Carefully Planned Travel, LLC

<html>
  <body>
    <form-template>&#13;
	<fields><field type="text" subtype="text" required="true" label="Email" className="form-control" name="email"></field>&#13;
		<field type="header" subtype="h2" label="Travel Insurance"/>&#13;
		<field type="header" subtype="h1" label="  "/>&#13;
		<field type="header" subtype="h2" label="Full name"/>&#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" label="Middle name" name="middle-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="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."/>&#13;
		<field type="radio-group" label="Please choose:" name="please-choose">&#13;
			<option label="I ACCEPT Travel Insurance." value="accept">I ACCEPT Travel Insurance.</option>&#13;
			<option label="I DECLINE Travel Insurance. I understand that this could result in the loss of ALL of my travel costs." value="decline">I DECLINE Travel Insurance. I understand that this could result in the loss of ALL of my travel costs.</option>&#13;
		</field>&#13;
	</fields>&#13;
</form-template>
  </body>
</html>

Click to sign