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					                                       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
24 hours or a                        Signature                                                 MSU Eagle ID
portion thereof.
                                     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

				
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