Fill - Free fillable International Insurance Form (California State University Channel Islands) PDF form



Traveler’sInformation

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Name(Last,First,MI.):

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Foreign

Travel

Insurance

Request

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ATTACH:TRIPITINERARY,APPROVEDTRAVEL

AUTHORIZATION,ROSTEROFTRAVELERS

ALLFIELDSMUSTBE

OMP

D

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Email: CellPhone: Alt.Phone:

Department: Chartfieldstringforpremiumchargeback:

PurposeofTrip

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Course(s): DepartureDate:ReturnDate:

Destination(s):

AreanyofthedestinationsontheStateDept.’s‘highhaza rd’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.

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http://www.calstate.edu/risk_management/rm/documents/CSURMA_HighHazardList.pdf

Traveler’sEmergencyContactInformation

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EmergencyContactPerson: Contact’sEmail:

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Group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.

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NumberofStudents: NumberofC.I.Employees: NumberofOthers*:

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*If‘Others’aretraveling,pleaseexplain:

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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

.

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Iftraveliscancelled,pleasenotifyRiskManagementatext.8846assoonaspossible.

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SENDCOMPLETEDFORM,ITINERARY,COPYOFTRAVELAUTHORIZATIONANDGROUP

LIST(IFAGROUPISTRAVELING)TORISK

EME

NT.

Revised2/2015

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International Insurance Form (California State University Channel Islands)

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