Student Trip Insurance - Morehead State University by panniuniu


									                                       STUDENT TRIP INSURANCE
                                          Morehead State University
                                   Office of Environmental Health & Safety
                                         Premium Remittance Report

Departure Information
           Date                                            Hour                          A.M. or P.M.
Return Information
           Date                                            Hour                          A.M. or P.M.

 Applicable           Total Number                                         Number                    Total
   Daily               of Days for          Total Premium                      of                  Premium
 Premium               Coverage*            Per Participant               Participants               Due
   $1.40          X                     =        $1.40            X                        =            $1.40

*One day is
                                                         Signature                              MSU Eagle ID
24 hours or a
portion thereof.
                                                 Printed or Typed Name

                                                 Organization or Class

*IMPORTANT: Complete the following steps
             1. If paying by cash, money should be deposited at CASHIER'S WINDOW at
                Howell-McDowell, cash code 729.
             2. If paying by requisition please provide account number. The on-line requisition will be
                completed by the Office of Environmental Health & Safety. ANY departmental budget
                account number may be used (i.e., supplies, special expenses, insurance, etc.)
                          List account number.                        -                    -

             3. Completed form, deposit slip when applicable, and a list of the students participating should
                be submitted a minimum of 72 hours prior to the date coverage is to become effective.

Return form to:
Office of Environmental Health & Safety
112 Downing Hall
Phone: 783-2179
Fax: 783-2359

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