Travel / Trip Cancellation Insurance: *

Your trip is a significant investment. Unique Romance Travel strongly recommends the purchase of travel cancellation insurance. If you choose to decline this valuable protection, you assume any financial loss associated with my travel arrangements. Unique Romance Travel is not liable or responsible for any expenses incurred as a result of cancellation and interruption, emergency medical/transportation, baggage and personal effects, flight and travel accident, and/or rental car physical damage.

I am not interested in purchasing Travel / Trip Cancellation Insurance and understand that cancellation penalties could be up to 100% of the cost of my vacation. If I do not purchase insurance, I am responsible for any cancellation penalties.

I am interested in purchasing Travel / Trip Cancellation Insurance.

Date *

MM

DD

YYYY

If you will be purchasing Travel Cancellation Insurance, please list the travelers it will be purchased for.

Passenger 1

First Name

Last Name

Passenger 2

First Name

Last Name

Passenger 3

First Name

Last Name

Passenger 4

First Name

Last Name

Date

MM

DD

YYYY

Your Name *

First Name

Last Name

Phone Number *

(###)

###

####

Cell Phone Number (if different from above)

(###)

###

####

Travel Departure Date

MM

DD

YYYY

Travel Return Date

MM

DD

YYYY

Name on Card *

First Name

Last Name

Billing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country