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Foreign Travel Insurance Request Form
Supplemental Form to be attached to the University/Foundation Travel Reqeust Form
In accordance with Technical Letter 2014-01, all faculty, staff, and students who travel internationally on CSU business are required to use the
Foreign Travel Insurance Program (FTIP) through the California State University Risk Management Authority (CSURMA) and report their trips
as soon as practical, but no less than 30 days prior to departure for international travel. Technical Letter 2014-01 delegates international
travel approval authority to the campus President unless travel is to a "War Risk" country in which case approval by Systemwide Risk
Management in the Chancellor's Office is required. Technical Letter 2014-01: http://www.calstate.edu/risk_management/rm/documents/RM-2014-01.pdf
Traveler's Information
First Name:
Last Name:
Title/Position:
Department/College
E-mail while traveling:
Traveler Status: Faculty Staff Student Volunteer
For Student Traveler:
Informed/Consent Waiver
Attached
Yes
No
Emergency Contact Information
This information will be used to communicate with your emergency contact in the U.S. and/or abroad, should an emergency occur while you are traveling outside of
the United States. Please include area code, city and country codes with phone numbers.
Traveler 's U.S. Cell Phone:
Traveler's Foreign
Cell Phone:
U.S. Emergency
Contact's Name:
U.S. Emergency
Contact's E-mail:
Relationship:
U.S. Emergency
Contact's Phone:
Other Emergency Contact
Information:
Purpose of Travel:
(select one or more)
Attending Conference Conducting Field Research Paper Presentation
Student Recruitment Teaching
Other
Travel Destination and Dates - Include all Regions, Cities and Towns
Date of U.S. Departure: Date of Return to
United States:
Destination City: Destination Country:
Additional Destinations?
If "YES" include information
below
Yes No
Additional Destination: From Date:
To Date:
Additional Destination: From Date: To Date:
Additional Destination: From Date: To Date:
Revised: March 2016
1
Emergency Contact Abroad:
Emergency Contact
Abroad's E-mail:
Relationship:
Emergency Contact
Abroad's Phone:
Airports Being Used:
Transportation To/From
Foreign Airport
(select all that apply)
Air Hired Car Hired Driver Rental Car Boat/Ship Bus
Train Other
Transportation To/From
Lodging and Site
(select all that apply)
Air Hired Car Hired Driver Rental Car Boat/Ship
Bus Train
Other
Travel to CSURMA High Hazard or U.S Department of State Travel Alert and Warning Destination
Travelers must review both the CSURMA High Hazard Country List and the U.S. Department of State Travel Alert or Warning list, using the links in this section, to
determine if any destination (including layovers) appears on either list. Checking either "Yes or No" will indicate that you have reviewed both lists. If any
destination appears on either list, please provide additional information on page 3.
Yes No
http://travel.state.gov/content/passports/english/alertswarnings.html
Traveler Enrolled in the U.S. Department of State STEP?
(Safe Traveler Enrollment Program)
Yes No
The Smart Traveler Enrollment Program (STEP) is a free service to allow U.S. citizens and nationals traveling abroad to enroll their trip with the nearest U.S. Embassy or
Consulate. The benefits of enrolling in the STEP program include receiving important information from the Embassy about safety conditions in your destination country, helping
you make informed decisions about your travel plans. helps the U.S. Embassy contact you in an emergency, whether natural disaster, civil unrest, or family emergency and
helps family and friends get in touch with you in an emergency.
https://step.state.gov/step/
Lodging/Accommodations
Where will you stay during
your trip?:
Hotel Private Residence
Other
Lodging Name:
Lodging Address:
Lodging Phone:
(include city and country
code)
Additional Lodging
Locations?
If "YES" , include information
below
Yes No
Additional Lodging Name:
Additional Lodging
Address:
Additional Lodging Phone:
(include city and country
code)
2
CSUM International Travel Authorization Form
CSURMA High Hazard and
"War Risk" Country Lis
t
Destination on High Hazard List
Destination on "War Risk" List
Yes
No
Yes
No
http://www.calstate.edu/risk_management/rm/documents/CSURMA_HighHazardList.pdf
Note: Travel to a "War Risk" destination requires the review and
approval by Systemwide Risk Management in the Chancellor's Office.
Safety Tips While Traveling Abroad
I have reviewed the "Safety Tips While Traveling Abroad" international travel orientation presentation, including the content about the specific country(ies) I will be visiting abroad
that is available from the following website:
Yes No
U.S. Department of State Travel Alert or Warning List
Facility Details
Facility Name:
Facility Site Location:
Facility Point of Contact:
Type of Site: Urban Rural Both Urban and Rural
Airline Trip Summary
Do you have a flight
itinerary?
Yes No
Please use the fields below to enter your flight information as accurately as possible.
Outbound
Departure Date:
Departure Time: From Airport: Airline Flight Number
Arrival Date:
Arrival Time: From Airport: Airline Flight Number
Return
Departure Date:
Departure Time: From Airport: Airline Flight Number
Arrival Date:
Arrival Time: From Airport: Airline Flight Number
3
If travel destinations include locations on either the CSURMA High Hazard, "War Risk" or U.S. Department of State Travel Alert or Warning list please
describe any safety and travel precautions planned for this trip. Please be advised that travel authorization may be rescinded at any time if risk
conditions change.
This information accurately reflects information related to my University travel. If any dates, locations or travel information changes, I will report
the updated information.
_______________________________________________________________
Traveler's Signature
_______________________________
Date
CSUM International Travel Authorization Form
Submit this document with your Approved California State University Maritime Academy
TRAVEL AUTHORIZATION FORM
to the Department of Safety & Risk Management for processing.
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Completed 16 July 2020

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