Foreign Travel Insurance Program (FTIP) Report & Request

Use this form to:

Report international travel to the Chancellor's Office
and

Request travel insurance from FTIP

Prior to reporting travel and requesting insurance, faculty members should first complete the Provost Office's International Travel Request Form.

FTIP Premium Quote

If you need a travel insurance premium quote only, please so indicate in the “Purpose of travel” box below by writing “Request for quote only,” and do not enter any accounting information in the chartstring box. If you decide to formally request insurance, please fill out the form again, including the accounting information in the chartstring box.

5/1/2011 Worldwide Travel Alert

Due to the current situaion, additional information will be needed. Please complete the form as indicated and as detailed as possible.

If you have any questions, please call or email Janie Xiong at (916) 278-6456 or xiong@csus.edu

Requester Information

Name: Phone Number:

Email: Dept Zip:

Department:

Payment: Chartstring:
Chartstring needs to include Account-Fund-Dept ID, not your 8 digit speedtype. Payment for the premiums will be deducted from department accounts. Please indicate if payment is to be made otherwise. Do not complete if requesting a quote.

Travel Information

Destination(s): Please include all cities and countries of destination.

From (Date): To (Date):

Purpose of travel (including names of conferences, activities, etc.):
Please include the following information:

Details regarding activities and research

Contact information for traveler while traveling

Contact information for traveler’s accommodations while abroad

What modes of travel will be used to move about in destination country? (i.e. rental car, public transportation, walking, etc...)

Airports traveler will be traveling to and from

Any specific security measures taken? (if none, so state)

If requesting only a quote, please indicate by writing "Request for quote only."

Traveler Information

Name of Primary Participant:

# of Faculty/Staff Participants:
Only indicate so if they need insurance for the same time frame.

# of Student Participants:
Only indicate so if students need insurance for the same time frame and are NOT covered through a different means.

# of Other Participants:

Please indicate if you wish to have other participants covered as well. Provide full name and relationship to the traveler.
Note: Non-employee participants has to be paid out of pocket. A statement will be sent to the requester for payment.

Please Double Check Your Information Before Submitting