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Foreign Travel Insurance Registration Form
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I. Requestor
* First Name:
spacer MI: spacer spacer * Last Name: spacer
* Department | College:
Course # (if applicable):
spacer * Phone Number: spacer - -
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* Purpose of Trip
(i.e.; conference title, reason for travel):
* Destination | Country #1:
Destination | Country #2:
Destination | Country #3:
* Departure Date:
spacer Calendar icon Select Date spacer * Return Date: spacer spacer Calendar icon Select Date
II. Person in charge on trip
* First Name:
spacer MI: spacer spacer * Last Name: spacer
* Department | College:
* Mobile Phone Number:
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Office Phone Number:
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FAX Number:
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* Email Address:
III. Participant Information
Number of Participants:
Students: spacer spacer Employees: spacer spacer Chaperones:
(Not Employees)		 spacer spacer Others:* spacer
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* If "Others" are on trip, please explain:
[family travelers may be insured at your own expense]
IV. Contact and Trip Information
Necessary information for Policy Activation.
Who should the University contact on your behalf in case of emergency?
(list full name and mobile phone number):
Name:
Phone Number:
 - -
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* Participant List:
(Please copy & paste participants names & phone numbers into window above)
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* Trip Itinerary:
[Include: flight numbers/times/dates, hotel name/address, cities/regions to visit, and mode of travel in country (bus, taxi, etc.)]
(Please copy & paste full daily trip itinerary into window above)
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California State University, Stanislaus
One University Circle
Turlock, CA 95382