Student Trip Travel - LSU Health Care Services

Completion of this form is not a guarantee of coverage. Travel must meet all requirements outlined by the insurance policy. If you have any questions or would like to discuss program coverage please contact the Office of Risk Management.

Campus

Name of Organization/Department

(e.g. School of Mass Communication, College of Engineering, etc.)

Destination

(e.g. Bluebonnet Swamp)

City

State

Mode of Travel

Who will be driving?

Driver's name

Drivers Contact Information

Date of Departure

mm/dd/yyyy

Date of Return

mm/dd/yyyy

Number of LSU Students Traveling

(Please insert a number, no text characters)

Contact Person

Name

Phone

(Use xxx-xxx-xxxx format)

Other Participants Traveling

Will you be traveling with non-LSU students or employees?

Yes

Number of Non-LSU Students or Non-LSU Employees Traveling

Please only enter a value greater than 0 if the person(s) traveling are not an LSU student or LSU Employee. No other text characters are needed.

Account Number

If coverage is being provided to anyone other than LSU Students please include an account number that will be billed at ten cents per person per day at the end of each semester. If Account is grant funded, please respond to your confirmation e-mail with the date that all charges should be processed.

Data Authorization

I authorize that all information provided on this form, including any and all personal, financial and academic data may be shared with the LSU Risk Management and university insurance carriers and vendors. This data will be securely retained indefinitely. To learn more about privacy at LSU, please see the LSU Privacy Statement.

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