Foreign Travel Insurance Registration Form

* Required Fields


REQUESTOR
(if applicable)
(area code first)
TRIP INFORMATION
(i.e.; conference title, reason for travel)
(ex: Taxi, Bus, Train)
[Please copy & paste full daily trip itinerary into window above. Include: flight numbers/times/dates, hotel name/address, cities/regions to visit, and mode of travel in country (bus, taxi, etc.)]
DESTINATION
REQUIRED if traveling in a high hazardous country
PARTICIPANT INFORMATION
Check all that apply
EMERGENCY CONTACT
*Necessary information for Policy Activation* The emergency contact needs to be someone the insurance can contact to make emergency/health medical decisions on your behalf.
Who should the university contact on your behalf in case of emergency? List full name
(area code first)
Safe Traveler Enrollment Program (STEP) - It is recommended all employees and students traveling internationally sign up for the U. S. State Department's Safe Traveler Enrollment Program (STEP). This is a system utilized by the State Department to connect with the traveler, providing information should conditions change in the foreign location and assist you in an emergency. The traveler need only enroll once and then can update as trips are planned.