Travel Reservation Form Page 4
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4Travel Insurance Waiver
PASSENGER 1:
)
(If applicable, please check the appropriate box
I decline to purchase any of the insurance plans listed below that my travel agent has offered and explained to me.
My credit card offers travel insurance benefits. Therefore, I do not wish to purchase any of the insurance plans listed
below that my travel agent has offered and explained to me.
•
•
Emergency Medical
Baggage & Personal Effect
•
•
Cancellation & Interruption
Rental Car Physical Damage
•
Flight Accident
I, the undersigned, will not hold my travel agent or Savuti Safari & Company Inc. responsible for any expenses incurred from
any sources as a result of:
a)
my refusal to purchase travel insurance;
b)
my selection of the principal sums and/or sums insured of the insurances(s) I have purchased;
c)
restricted benefits, conditions and/or exclusions related to my credit card travel insurance;
d)
insufficient protection offered by my credit card travel insurance; or
e)
non-existing coverage of my credit card travel insurance.
Signature:
Print name: __________________________________
__________________________________________
Travel agent’s signature:
Date: _______________________________________
_______________________________
PASSENGER 2:
)
(If applicable, please check the appropriate box
I decline to purchase any of the insurance plans listed below that my travel agent has offered and explained to me.
My credit card offers travel insurance benefits. Therefore, I do not wish to purchase any of the insurance plans listed
below that my travel agent has offered and explained to me.
•
•
Emergency Medical
Baggage & Personal Effect
•
•
Cancellation & Interruption
Rental Car Physical Damage
•
Flight Accident
I, the undersigned, will not hold my travel agent or Savuti Safari & Company Inc. responsible for any expenses incurred from
any sources as a result of:
a)
my refusal to purchase travel insurance;
b)
my selection of the principal sums and/or sums insured of the insurances(s) I have purchased;
c)
restricted benefits, conditions and/or exclusions related to my credit card travel insurance;
d)
insufficient protection offered by my credit card travel insurance; or
e)
non-existing coverage of my credit card travel insurance.
Print name: __________________________________
Signature: __________________________________________
Date: _______________________________________
Travel agent’s signature: _______________________________
Page 4 of 4
Safari & Company 95 Hanson Street, Toronto, ON, Canada M4C 5P3
Toll Free: 1 800 303 6799 Phone: 416 642-0712 Fax: 416 507-9874
Travel Industry Council of Ontario Registration #: 50012750
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Parent category: Life