Share your information with Sea la Vie Travel, Andrea Miner

Sea la Vie Travel, Andrea Miner

Sea La Vie Travel

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		<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="text" label="Suffix" name="suffix" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Preferred name" name="preferred-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="date" label="Birthday" name="birthday" 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" label="State" name="address-state" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Zip" name="address-zip" subtype="text" className="form-control"/>&#13;
		<field type="textarea" label="Are there other people in your household that are traveling with you? If so, may I have the full names and dates of birth?" name="textarea-1681239198951" className="form-control"/>&#13;
		<field type="radio-group" label="Do you reside in the same household?&amp;nbsp;" description="Do you reside under the same roof?" name="do-you-reside-in-the-same-household-">&#13;
			<option label="Yes" value="yes">Yes</option>&#13;
			<option label="No" value="no">No</option>&#13;
		</field>&#13;
		<field type="checkbox-group" label="There are two different policies that I can provide a quote for medical only and medical with trip coverage.&amp;nbsp; The medical with travel coverage will be more expensive but will have coverage for travel delays, travel cancellations, baggage coverage, etc. This will be more detailed in the quote, this is not a cancel for any reason policy. Would you like a quote for medical only or medical and trip coverage.&amp;nbsp;" name="there-are-two-different-policies-that-i-can-provide-a-quote-for-medical-only-and-medical-with-trip-coverage-the-medical-with-travel-coverage-will-be-more-expensive-but-will-have-coverage-for-travel-delays-travel-cancellations-baggage-coverage-etc-this-will-be-more-detailed-in-the-quote-this-is-not-a-cancel-for-any-reason-policy-would-you-like-a-quote-for-medical-only-or-medical-and-trip-coverage-">&#13;
			<option label="Medical Only Quote" value="medical-only-quote">Medical Only Quote</option>&#13;
			<option label="Medical and Trip Protection Quote - two plans will be offered." value="medical-and-trip-protection-quote-two-plans-will-be-offered">Medical and Trip Protection Quote - two plans will be offered.</option>&#13;
		</field>&#13;
		<field type="header" subtype="h1" label="There is some information additional information that I will need to provide the most accurate quote."/>&#13;
		<field type="date" label="Date you are leaving the US for trip?" name="date-you-are-leaving-the-us-for-trip" className="form-control"/>&#13;
		<field type="date" label="Date you are returning back to the US from this trip?" name="date-you-are-returning-back-to-the-us-from-this-trip" className="form-control"/>&#13;
		<field type="date" required="true" label="What was the date of your first payment towards this trip?" name="what-was-the-date-of-your-first-payment-towards-this-trip" className="form-control"/>&#13;
		<field type="text" label="What is the total non-refundable cost of your trip? This is the total of what you would loose if the trip was to cancel for an unforeseen reason.&amp;nbsp; Air, tour, additional items outside the planned tour, etc. **This is only needed if you would like a quote to cover trip expenses**" name="what-is-the-total-nonrefundable-cost-of-your-trip-this-is-the-total-of-what-you-would-loose-if-the-trip-was-to-cancel-for-an-unforeseen-reason-this-is-only-needed-if-you-would-like-a-quote-to-cover-trip-expenses" subtype="text" className="form-control"/>&#13;
		<field type="radio-group" label="I need to allocate the trip expenses per traveler. Is the total cost of the trip evenly divided between the travelers in your household? ie. Traveler #1 is paying air by points, Traveler #2 paid air by cash. Traveler #1 trip expenses are different than Travel #2.&amp;nbsp; Are you paying the same amount for each traveler?&amp;nbsp;" name="i-need-to-allocate-the-trip-expenses-per-traveler-is-the-total-cost-of-the-trip-evenly-divided-between-the-travelers-in-your-household-ie-traveler-1-is-paying-air-by-points-traveler-2-paid-air-by-cash-traveler-1-trip-expenses-are-different-than-travel-2-are-you-paying-the-same-amount-for-each-traveler-">&#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="I understand that Sea la Vie Travel is not a licensed insurance agent and have been requested to offer travel protection to you for your trip. I agree to the Terms and Conditions https://sealavietravel.com/terms-and-conditions" name="i-understand-that-sea-la-vie-travel-is-not-a-licensed-insurance-agent-and-have-been-requested-to-offer-travel-protection-to-you-for-your-trip-i-agree-to-the-terms-and-conditions-httpssealavietravelcomtermsandconditions">&#13;
			<option label="I agree" value="i-agree">I agree</option>&#13;
		</field>&#13;
		<field type="paragraph" subtype="p" label="Thank you for filling out this information.&amp;nbsp; I will be sending you a quote within 24-48 business hours. If you have any questions please feel free to contact me. This quote will detail the plan and coverage. If you want to purchase the plan, you may do so directly from the quote or contact me by phone or email. Andrea Miner | Sea la Vie Travel | 303-435-5121 | andrea@sealavietravel.com"/>&#13;
	</fields>&#13;
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