Faculty & staff participating in GVSU affiliated international travel must use this form to register for the GVSU International Accident and Sickness Insurance program.   

Registering will ensure that travelers are covered under all applicable GVSU assistance and insurance policies. Registration also assists the Padnos International Center in keeping travelers informed as much as possible of potential risks (health/safety, financial, IT security, Research Compliance, etc.). In case of an emergency, we can best assist you if your trip is registered and your travel details are listed.  

Costs

• Faculty and staff will have access to this plan free of charge while on GVSU sponsored travel. 
• Spouses and dependents of GVSU faculty traveling on university-related business are eligible for the university's optional international accident and sickness insurance. The faculty/staff member is responsible for purchasing the insurance and paying for all costs associated with family members' coverage.
  • IMPORTANT: To calculate the number of days, you can use a date calculator. The daily rate is $1.91 for spouses and dependents (rates are subject to change). If travel exceeds 100 days, please reach out to [email protected]. 

Key Considerations

If you are traveling to any embargoed/sanctioned/prohibited country on behalf of GVSU and/or taking any GVSU-owned items to these locations, you are required to notify the Office of Research Compliance and Integrity. Additionally, regardless of your international destination, if you are taking a GVSU-owned device that contains enhanced encryption software (including, but not limited to, VPN software [such as GlobalProtect or Ivanti VPN] and SAS statistical software), you will need to contact the Office of Research Compliance and Integrity for further export documentation. They can be reached at [email protected], or by calling (616) 331-3197. 

NOTE: This is specifically for international university-related travel. Please fill out separate forms for each traveler. 

First Name *

Last Name *

Email *

Phone *

Traveler Status *
Faculty
Staff
Spouse/Dependent

Number of GVSU Affiliated Travel Days *
- Select Option 1 ($1.91) 2 ($3.82) 3 ($5.73) 4 ($7.64) 5 ($9.55) 6 ($11.46) 7 ($13.37) 8 ($15.28) 9 ($17.19) 10 ($19.10) 11 ($21.01) 12 ($22.92) 13 ($24.83) 14 ($26.74) 15 ($28.65) 16 ($30.56) 17 ($32.47) 18 ($34.38) 19 ($36.29) 20 ($38.20) 21 ($40.11) 22 ($42.02) 23 ($43.93) 24 ($45.84) 25 ($47.75) 26 ($49.66) 27 ($51.57) 28 ($53.48) 29 ($55.39) 30 ($57.30) 31 ($59.21) 32 ($61.12) 33 ($63.03) 34 ($64.94) 35 ($66.85) 36 ($68.76) 37 ($70.67) 38 ($72.58) 39 ($74.49) 40 ($76.40) 41 ($78.31) 42 ($80.22) 43 ($82.13) 44 ($84.04) 45 ($85.95) 46 ($87.86) 47 ($89.77) 48 ($91.68) 49 ($93.59) 50 ($95.50) 51 ($97.41) 52 ($99.32) 53 ($101.23) 54 ($103.14) 55 ($105.05) 56 ($106.96) 57 ($108.87) 58 ($110.78) 59 ($112.69) 60 ($114.60) 61 ($116.51) 62 ($118.42) 63 ($120.33) 64 ($122.24) 65 ($124.15) 66 ($126.06) 67 ($127.97) 68 ($129.88) 69 ($131.79) 70 ($133.70) 71 ($135.61) 72 ($137.52) 73 ($139.43) 74 ($141.34) 75 ($143.25) 76 ($145.16) 77 ($147.07) 78 ($148.98) 79 ($150.89) 80 ($152.80) 81 ($154.71) 82 ($156.62) 83 ($158.53) 84 ($160.44) 85 ($162.35) 86 ($164.26) 87 ($166.17) 88 ($168.08) 89 ($169.99) 90 ($171.90) 91 ($173.81) 92 ($175.72) 93 ($177.63) 94 ($179.54) 95 ($181.45) 96 ($183.36) 97 ($185.27) 98 ($187.18) 99 ($189.09) 100 ($191.00)

How many countries are you traveling to? *
1
2
3
4

Country #1: Please List all Cities and Dates you will be in each City *

DESTINATION #1: Date of Arrival in Country *
- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 - 2035 2034 2033 2032 2031 2030 2029 2028 2027 2026 2025

DESTINATION #1: Date of Departure from Country *
- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 - 2035 2034 2033 2032 2031 2030 2029 2028 2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900

Country #2: Please List all Cities and Dates you will be in each City *

DESTINATION #2: Date of Arrival in Country *
- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 - 2035 2034 2033 2032 2031 2030 2029 2028 2027 2026 2025

DESTINATION #2: Date of Departure from Country *
- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 - 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900

Country #3: Please List all Cities and Dates you will be in each City *

DESTINATION #3: Date of Arrival in Country *
- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 - 2035 2034 2033 2032 2031 2030 2029 2028 2027 2026 2025

DESTINATION #3: Date of Departure from Country *
- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 - 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900

Country #4: Please List all Cities and Dates you will be in each City *

DESTINATION #4: Date of Arrival in Country *
- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 - 2035 2034 2033 2032 2031 2030 2029 2028 2027 2026 2025

DESTINATION #4: Date of Departure from Country *
- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 - 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900

Purpose of Travel (Please be as detailed as possible) *

Hotel/Lodging Address (Optional): Please list all applicable addresses associated with your trip

Passport Upload *
Please upload a file with the extension .csv, .xls, .ppt, .doc, .pdf, .psd, .rtf, .pages, .docx, .odt, .pptx, .xlsx, .pub, .zip, .mp3, .mpg, .bmp, .gif, .jpeg, .jpg, .png, .tiff, .webp, .txt, .mp4, .qt, .wma, or .wmv with a maximum size of 1 MB (1024 KB)

Flight Itinerary (Optional)
Please upload a file with the extension .csv, .xls, .ppt, .doc, .pdf, .psd, .rtf, .pages, .docx, .odt, .pptx, .xlsx, .pub, .zip, .mp3, .mpg, .bmp, .gif, .jpeg, .jpg, .png, .tiff, .webp, .txt, .mp4, .qt, .wma, or .wmv with a maximum size of 1 MB (1024 KB)