MSUB FACULTY/STAFF FOREIGN TRAVEL
INSURANCE REPORTING FORM
**Please send it via campus mail to: businessoffice@msubillings.edu or fax completed form to Risk
Managem
ent and Safety at (406) 657-2051
The below information must be reported to MSUB Risk Management & Safety for each trip to a foreign
country or destination by EACH MSUB faculty or staff member prior to departure. Reporting all travel
plans will confirm that foreign worker’s compensation insurance coverage, foreign liability insurance
coverage and travel assistance services are in effect for the employee’s foreign travel.
EMPLOYEE NAME: _____________________________________________________________
DEPARTMENT: ________________________________________________________________
TRAVELING TO (list all countries, cities not necessary):
PURPOSE OF TRAVEL: ________________________________________________________
DATE OF DEPARTURE: ________________________________________________________
DATE OF RETURN: ____________________________________________________________
WILL STUDENTS ALSO PARTICIPATE IN TRAVEL?: Yes No
WILL OTHER FACULTY/STAFF PARTICIPATE IN TRAVEL?: Yes No
WILL FAMILY MEMBER(S) PARTICIPATE IN TRAVEL?: Yes No
