STUDENT TRIP INSURANCE
Morehead State University
Office of Environmental Health & Safety
Premium Remittance Report
Activity
Destination
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
Date
*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