Foreign travel Insurance Request Form

Risk Management & Insurance

Foreign Travel Insurance
Request Form

RISK MANAGEMENT

Phone: (818) 677-2079

Mail Drop: 8284

I. Requestor's Name:
NAME (Last, First, MI):	PHONE NO:
DEPARTMENT/COLLEGE:	COURSE (If Applicable):
PURPOSE OF TRIP:
DESTINATION (All Locations):	RETURN DATE:

II. Person in charge on trip:
PHONE NO:	ALT PHONE:	FAX NUMBER:
EMAIL ADDRESS:

III. Participant Information:
# STUDENTS:	# EMPLOYEES:	# CHAPERONES (Not Employees):	# OTHERS:*
* If "Others" are on trip, please explain:

IV. Emergency Contact Information: (NECESSARY FOR POLICY ACTIVATION)
PARTICIPANTS LIST:	PLEASE ATTACH SEPERATE LIST WITH NAME(S)/PHONE # OF ALL PARTICIPANTS.
TRIP ITINERARY:	PLEASE ATTACH A FULL DAILY TRIP ITINERARY.

V. Check one (1) for Risk Management Reply:
	PLEASE PROVIDE AN ESTIMATE PREMIUM FOR TRAVEL INSURANCE.
	PLEASE PROVIDE A TRAVEL INSURANCE POLICY AS INDICATED ABOVE.
VI. Full Account string to be charged for insurance premium (if applicable).

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