Name

Country/Countries to be visited

Place of Work

Date of Return

Should there arise a need to get in touch with me while I am away, I can be reached at the following address:

Address

Telephone

I fully understand that it is my responsibility to provide Travel Insurance for my trip. Therefore:

I have purchased Travel Accident and Emergency Health Insurance for my trip and a copy of the policy is enclosed.

Please arrange Insurance Coverage for my trip and arrange for deduction of the premium.

Approved by Supervisor

Supervisor Signature

To be filled in by Conference Treasurer (check box) before committee action:

This individual is a worker and is covered by adequate Travel Accident and Emergency Health Insurance.

This individual is not a worker with adequate Travel Accident and Emergency Health Insurance, but has satisfied me that he/she secured adequate Travel Accident and Emergency Health Insurance.

This individual is requesting short term travel coverage per attached order and check attached is to cover the cost.

Treasurer's Signature

Date

Secretary Signature

Request Approved Request Not Approved

Date of Committee Action

Date Signed