Job Crisis / Medical Cancellation Waiver

This form must be filled out completely by both subscriber (sections 1 & 3) and by the person to whom the subscriber reports (section 2) in order to be submitted to our insurer. Please leave no question blank. If you have any trouble filling out any question, please contact one of our offices.

1. Subscriber, please complete the following section:

Your Name:

Employer:

Employer’s Address:



How long have you been employed by this firm?

Job Title:

Division or Department:

A work telephone number where you can be reached:


2. Please request that the person to whom you report complete the following section:

Name:

Title:

Telephone / e.mail:

Name, title, phone number and e.mail address of a manager who can be contacted in your absence:


Supervisor Signature:


3. Subscriber: please read and sign the following. Then return to Blue Marble Travel

“I, the undersigned, have read and understand the terms and conditions of applying to Blue Marble Travel's Discovery Cycle Trips, and especially the “Trip Protection” section of the “Commitment Issues” page.

“I understand that the waiver to which I am hereby subscribing is automatically invalidated by any false or incorrect statment made on this form.”

Date:

Signature of Subscriber: