<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 Waiver"/> <field type="header" subtype="h1" label=" "/> <field type="paragraph" subtype="p" label="Thank you for consulting with our agency for your travel needs. We value your business and appreciate the time you have spent with us to build your dream vacation.&nbsp; Travel insurance in the amount of $179 will cover your Cancun Trip from&nbsp; November 6-8, 2025&nbsp; The total cost for your trip is $1308 in which a&nbsp; Vacation Protection Plan Plus rate was provided.&nbsp;"/> <field type="header" subtype="h1" label="Waiver of Travel Insurance Coverage"/> <field type="paragraph" subtype="p" label="Please read this carefully! You are a valued client and we want to do everything possible to make your trip enjoyable and worry free. Because the unforeseen and unexpected can occur - before you leave or when you’re away from home - we recommend the Allianz Plan, It offers excellent benefits and combines insurance coverage with Emergency Hotline Services. Please read the Allianz brochure carefully for more information."/> <field type="radio-group" required="true" label="Please choose I ACCEPT or I DECLINE Travel Insurance:" name="please-choose"> <option label="I ACCEPT Travel Insurance." value="accept">I ACCEPT Travel Insurance.</option> <option label="I DECLINE Travel Insurance. Do not enroll me for the Vacation Protection Plus Plan. I understand that I am responsible for any cancellation penalties and out-of-pocket expenses incurred. I will also make my own provisions in the event of an emergency while I am traveling." value="i-decline-travel-insurance-do-not-enroll-me-for-the-vacation-protection-plus-plan-i-understand-that-i-am-responsible-for-any-cancellation-penalties-and-outofpocket-expenses-incurred-i-will-also-make-my-own-provisions-in-the-event-of-an-emergency-while-i-am-traveling">I DECLINE Travel Insurance. Do not enroll me for the Vacation Protection Plus Plan. I understand that I am responsible for any cancellation penalties and out-of-pocket expenses incurred. I will also make my own provisions in the event of an emergency while I am traveling.</option> </field> <field type="text" required="true" label="If I'm forced to cancel or interrupt my trip, I will forfeit up to the total full travel cost if I have DECLINED travel insurance. Please enter the amount of your full trip.&nbsp;" name="if-im-forced-to-cancel-or-interrupt-my-trip-i-will-forfeit-up-to-the-total-full-travel-cost-shown-below" subtype="text" className="form-control"/> <field type="text" required="true" label="INSURANCE COST: You can protect your valuable travel investment for only $179.00. Does this amount match the insurance quote you were provided:" name="allianz-plan-cost-you-can-protect-your-valuable-travel-investment-for-only-67600-does-this-amount-match-the-insurance-quote-you-were-provided" subtype="text" className="form-control"/> <field type="text" label="Full Name and Email Address to acknowledge receipt and submission of this form.&nbsp;" name="full-name-and-email-address-to-acknowledge-receipt-and-submission-of-this-form-" subtype="text" className="form-control"/> <field type="date" required="true" label="Date Field" name="date-1704578512866" className="form-control"/> </fields> </form-template> </body> </html>
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