Traveler’s Information
Name (Last, First, MI.):
Foreign
Travel
Insurance
Request
F
o
rm
ATTACH: TRIP ITINERARY, APPROVED TRAVEL
AUTHORIZATION, ROSTER OF TRAVELERS
ALL FIELDS MUST BE
C
OMP
LE
T
E
D
Email: Cell Phone: Alt. Phone:
Department:
Purpose of Trip
Course(s): Departure Date: Return Date:
Destination(s) – Provide countries and cities:
Will traveler be renting a vehicle? YES NO
Are any of the destinations on the State Dept.’s ‘high hazard’ or travel warning lists? YES NO
http://travel.state.gov/content/passports/english/alertswarnings.html
If YES, have you received appropriate approvals from the campus President? YES NO
Are any destinations on the War Risk list? YES NO
If YES, the Chancellor’s office will require 30 days to process approval.
ht
tp://www.calstate.edu/risk_management/rm/documents/CSURMA_HighHazardList.pdf
Traveler’s Emergency Contact Information
Emergency Contact Person: Contact’s Email:
Number of Students: Number of C.I. Employees: Number of Others*:
*If ‘Others’ are traveling, please explain:
Gro
up Information – Please attach separate sheet if a group is traveling, including names and email
addresses of all travelers in the group, and names and email addresses for each traveler’s emergency
contact.
Risk Management will send an email confirming that coverage has been bound for the traveler(s), along
with Travel Assist cards that each participant must carry while
trave
lin
g
.
If travel is canceled, please notify Risk Management at ext. 8846 as soon as possible.
SEND COMPLETED FORM, ITINERARY, COPY OF TRAVEL AUTHORIZATION AND GROUP
LIST (IF A GROUP IS TRAVELING) TO RISK
MA
N
A
G
EME
NT.
Revised 6/2018
