International Business Travel Insurance Form

All Appalachian State University employees traveling abroad on official university-related business must enroll in the International Business Travel Insurance plan.

If you are a student, this is not the insurance you need.

Submit this form, as well as an Official Travel Authorization, passport copy, and any payments for dependents, to enroll.

Personal Information

Title: *

Last Name: *

First Name: *

Middle Name:

Suffix:

E-mail Address: *

Travel Information

Departure Date: *

Month

Day

Year

Return Date: *

Month

Day

Year

Countries of Destination: *

Exact Location(s) of Your Stay Overseas: *

This can be your hotel, a University, conference location, etc. This will be given to GeoBlue should an emergency arise during your trip.

Personal Days *

Please enter the number of personal days you are taking during your trip.

Travel Purpose: *

Department: *

College: *

Type of Coverage Requested:

If you enroll a dependent, you must fill out all applicable information and calculate your payment. Multiply the daily dependent premium by the number of travel days (including days of departure from and return to the U.S.). Further instructions on payment are included in the confirmation when form is submitted.

Type of Coverage: *

You are financially responsible for insurance premiums covering any accompanying dependent(s) not on "official business" travel with Appalachian State University. Please note that coverage for dependents is not required, but strongly recommended.

Dependent 1 Information

Title:

Last Name:

First Name:

Gender:

Relationship to You:

Birthdate:

Month

Day

Year

Departure Date:

Month

Day

Year

Return Date:

Month

Day

Year

Dependent 2 Information

Title:

Last Name:

First Name:

Gender:

Relationship to You:

Birthdate:

Month

Day

Year

Departure Date:

Month

Day

Year

Return Date:

Month

Day

Year

Dependent 3 Information

Title:

Last Name:

First Name:

Gender:

Relationship to You:

Birthdate:

Month

Day

Year

Departure Date:

Month

Day

Year

Return Date:

Month

Day

Year

Emergency Contact- U.S.

Emergency Contact Name: *

List one contact in the U.S. OIP may contact in case of emergency.

Phone Number *

E-mail Address: *

Relationship to You: *

Emergency Contact - Overseas 1

Emergency Contact Name: *

List one contact abroad OIP may contact in case of emergency. If there is none put N/A.

Phone Number *

E-mail Address:

Physical Address: *

Emergency Contact - Overseas 2

Emergency Contact Name:

List one contact abroad OIP may contact in case of emergency.

Phone Number

E-mail Address:

Physical Address:

Emergency Contact - Overseas 3

Emergency Contact Name:

List one contact abroad OIP may contact in case of emergency.

Phone Number

E-mail Address:

Physical Address:

Disclaimer: *

I have read and understand the disclaimer listed below.

I agree to follow all University policies and procedures on obtaining international travel insurance and complying with export control regulations. Any Appalachian State University employee who travels abroad without having completed both the Travel Authorization and the International Travel Insurance forms personally assumes full responsibility for health and safety, and such failure to comply with procedure may result in denial of Travel Reimbursement expense.

Passport Copy

You must send your passport copy (via fileshare.appstate.edu or in person) to OIP prior to travel. Your insurance cannot be processed without it. (When sending via fileshare.appstate.edu, share your upload with ibtinsurance@appstate.edu.) *

I agree and will send it (if I have not already)

Leave this field blank

Office of International Programs

International Business Travel Insurance Form