Employee Information
Employee Information
If you are requesting insurance for more then one person, please complete this form for each person or attach a sheet with each travelers name, LSU ID, email, and phone number.
Name
*
If attaching group list, please type "See Attachment".
LSU ID Number
*
If attaching group list, please type "See Attachment".
Email Address
*
If attaching group list, please type "See Attachment".
Contact Number
*
If attaching group list, please type "See Attachment".
Payroll while travelling
*
For annual employees, divide annual salary by 365 x number of days traveling. If attaching group list, please type "See Attachment".
Trip Information
Trip Information
Departure Date
*
Return Date
*
Country(s) travelling to
*
City(s) travelling to
*
Sponsor of Travel
*
ie: State Department, Department of Defense
Summary of Scope of Services
*
Billing Information
Billing Information
Department Contact
*
Department Email
*
Department Phone Number
*
Program Number or Grant Number
*
Required Attachments
Required Attachments
*
Please attach: - Itinerary - Contract/Grant
Drop your files here
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