TRAVEL INSURANCE DECLINATION FORM

Affiliate of Cornerstone Collective

1021 61st Street, Suite B500 | Galveston, Texas 77551 Phone: 281-968-8108 | Website: travelwithcornerstone.com

IMPORTANT — PLEASE READ BEFORE SIGNING

Rick Oelkers/Ramblin With Rick Services LLC is required to inform all clients about the availability of travel insurance and the significant financial risks of traveling without it. This form documents your decision to decline travel insurance for the trip described below.

This is not a decision to take lightly. Travel insurance can protect thousands of dollars in non-refundable travel costs and provide peace of mind in the event of unexpected circumstances.

CLIENT AND TRIP INFORMATION

WHAT TRAVEL INSURANCE CAN COVER

Comprehensive travel insurance policies typically provide coverage for some or all of the following. By declining, you are accepting the financial risk associated with each of these events.

Trip Cancellation & Interruption

• Illness or injury of traveler or immediate family member
• Death of traveler or immediate family member
• Unexpected job loss or required military deployment
• Natural disasters, severe weather, or travel warnings issued after booking
• Potential loss if uninsured: Up to 100% of total trip cost

Medical Expenses Abroad

• Emergency medical treatment at your destination
• Hospitalization costs in foreign countries
• Prescription medications required during travel
• Potential out-of-pocket cost: $5,000–$100,000+

Emergency Medical Evacuation

• Medically necessary emergency transport back to the United States
• Air ambulance services
• Potential out-of-pocket cost: $15,000–$200,000+

Baggage Loss, Damage, or Delay

• Lost or stolen luggage and personal belongings
• Delayed baggage requiring purchase of emergency items
• Potential loss: $500–$5,000+

Travel Delays

• Covered expenses for meals and accommodations due to significant delays
• Missed connection costs

Cancel for Any Reason (CFAR) — Optional Upgrade

• Some policies offer the option to cancel for any reason and receive partial reimbursement
• Must typically be purchased within 10–14 days of initial deposit

INSURANCE QUOTE OFFERED

Rick Oelkers/Ramblin With Rick Services LLC has offered to provide travel insurance information and quotes for this trip.

DECLINATION STATEMENT

I/We, the undersigned, hereby decline travel insurance for the trip detailed above. I/We acknowledge and understand the following:

1. Voluntary Decision: This is my/our voluntary decision. I/We have been informed of the availability of travel insurance and have been provided with or offered the opportunity to review insurance options.
2. Financial Risk Acceptance: I/We accept full financial responsibility for all losses that may occur, including but not limited to: trip cancellation penalties, medical expenses abroad, emergency evacuation costs, baggage losses, and travel delays. I/We understand that these costs can be substantial.
3. Cancellation Penalties: I/We understand that if I/we cancel my/our trip for any reason, including illness, family emergency, or unforeseen circumstances I/we will be subject to the full cancellation penalties outlined in the Cancellation Policy. I/we have received, and no refund may be available.
4. Medical Coverage: I/We understand that my/our domestic health insurance (if applicable) may provide limited or no coverage for medical treatment outside the United States. I/We accept responsibility for any medical costs incurred during international travel.
5. Emergency Evacuation: I/We understand that emergency medical evacuation from a foreign country can cost tens of thousands of dollars and that I/we will be personally responsible for these costs without insurance coverage.
6. No Agent Liability: I/We agree that Rick Oelkers/Ramblin With Rick Services LLC and Cornerstone Collective shall have no liability for any financial losses, medical expenses, or other costs that could have been covered by travel insurance that I/we chose to decline.
7. Opportunity to Reconsider: I/We understand that I/we may reconsider and purchase travel insurance at any time prior to departure, though some benefits (such as pre-existing condition waivers and CFAR coverage) are only available within a limited window after initial deposit. Agent can assist with a quote at any time.

REASONS FOR DECLINATION (Optional — for Agent’s records)

ACKNOWLEDGMENT AND SIGNATURE

BY SIGNING BELOW, I/WE CONFIRM:

1. I/We have been offered the opportunity to purchase travel insurance for this trip.
2. I/We have been informed of the risks of traveling without insurance.
3. I/We fully understand and accept the financial risks outlined in this form.
4. I/We voluntarily decline travel insurance coverage.
5. I/We release Rick Oelkers/Ramblin With Rick Services LLC and Cornerstone Collective from any liability for losses that travel insurance would have covered.

Primary Traveler:

Co-Traveler (if applicable):

Travel Agent Witness:

Note: Even after signing this form, you may change your mind and purchase travel insurance at any time prior to departure. Contact your agent for a current quote.