Foreign Travel Insurance Registration Form

REQUESTOR
(if applicable)
(area code first)
(i.e.; conference title, reason for travel)
(ex: Taxi, Bus, Train)
PARTICIPANT INFORMATION
(To be indicated in "Participant List" below.)
CONTACT AND TRIP INFORMATION
*Necessary information for Policy Activation*
(Who should the university contact on your behalf in case of emergency? List full name)
(area code first)
(Please copy & paste participants names & phone numbers into window above)
[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.)]
REQUIRED if traveling in a high hazardous country