Travel Insurance by Robbie Bulus May 29, 2015 I understand that I may purchase travel insurance to cover certain risks inherent in travel such as supplier bankruptcy and the inability to travel due to a medical or personal emergency. Please check and initial your acceptance or refusal of travel insurance below.Full Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Travel Agent Name*Select Your Travel Agent. . .Amanda MillerAmy BassAmy RobertsAngela HenzAshley DunnBritney MoranCari FisherCarla BandeiraCarla KingChristine MushalCori BarberDavid ConklinDavid MerrickDavid SilipigniFatimah DevlinGail GallawayGinger AcostaJames KingJenni AicheleJennifer GallionJeremy GainesKatey BrownKatie BattenKathy MeserveKellye HenckelmanKim HickmanKristy KingLarysa HaleyLindsey FarleyLindsey ThibeaultMary Beth WallsMary DeAngelisMelissa SchulzMichelle DuniganMichelle SharpeMichelle SpanosMiriya WhitakerMorgan SotoMyra SupetranNicole LarsenRamona O'HearneRobbie BulusRyan HorneSharon BakerSharon JohnsonSuzanne RuthvenSylvia MasseyTheresa ScherzingerTherese DiecidueTorie JonesWalter TrainumWendi LambrightChoose One* I wish to purchase Travel Insurance. I do not wish to purchase Travel Insurance. Initials*World of Magic Travel (WOMT) acts as a sales agent for any airline, hotel, car-rental company, tour operator, cruise line, or other service provider named in your itinerary (Suppliers). WOMT is not responsible for acts or omissions of the Suppliers, their failure to provide services or adhere to their own schedules, their failure to pay any refund, or for any personal injury, property damage, or other loss, accident, delay, inconvenience, or irregularity which may be caused by any party not under WOMT's control. By accepting, you hereby agree to release WOMT from all claims arising out of any problem covered in this paragraph, to submit all other claims within 30 days after the return of your trip, and to litigate exclusively in the courts in Montgomery County, Texas.Date* Date Format: MM slash DD slash YYYY Signature*CaptchaCommentsThis field is for validation purposes and should be left unchanged.