Accident Insurance for Campus Events

Completion of this form is not a guarantee of coverage. Events 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

LSU A&M

Organization/Department Name

Organization Type

Select or enter value

Type of Event

Select or enter value

Event Name

Event Start Date

Event End Date

Number of LSU Students Participating

Will non-LSU Students (any other person) be participating in your event?

Yes

Number of Non-LSU Students Participating

Please only enter a value greater than 0 if the person(s) participating 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.

Will Participants be traveling Off-Campus

Yes

Primary Contact Person

Primary Contact E-mail

Primary Contact Phone #

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.

Send me a copy of my responses

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