Defense Base Act Insurance Request

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

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

Department Contact*

Department Email*

Department Phone Number*

Program Number or Grant Number*

Required Attachments

File Attachments*

Please attach: - Itinerary - Contract/Grant

Drag and drop files here or

Send me a copy of my responses

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