Foreign Travel Insurance Request
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TRIP ITINERARY MUST BE
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ALL BLANKS MUST BE
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SEND COMPLETED FORM TO RISK MANAGEMENT
C.I. Risk Management 11/2013
Traveler’s Information
Name (Last, First, MI.):
Email: Cell Phone: Alt. Phone:
Department: Chartfield string for premium chargeback:
Purpose of Trip
Course(s): Departure Date: Return Date:
Destination(s):
Are any of the destinations on the high hazardous/State Dept. travel warning list? YES NO
If yes, have you received appropriate approvals from the campus President and
the Chancellor? YES NO
Traveler’s Emergency Contact Information
Emergency Contact Person: Phone:
Participant Information
Number of Students: Number of C.I. Employees: Number of Others*:
*If ‘Others’ are traveling, please explain:
Attach separate list with name(s) and phone numbers of all students and other participants.
Risk Management will email confirmation the coverage has been bound for the traveler(s),
along with Travel Assist cards that each participant must carry while traveling.
Attach a copy of the confirmation email to the Request for Approval of Travel Form.
If travel is cancelled, please notify Risk Management at ext. 8846 as soon as possible.
Send completed form, itinerary and list of participants to Katharine Hullinger, Risk Mgr., Lindero Hall 1788,
or email information to katharine.hullinger@csuci.edu.
