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
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 *
DESTINATION #1: Date of Departure from Country *
Country #2: Please List all Cities and Dates you will be in each City *
DESTINATION #2: Date of Arrival in Country *
DESTINATION #2: Date of Departure from Country *
Country #3: Please List all Cities and Dates you will be in each City *
DESTINATION #3: Date of Arrival in Country *
DESTINATION #3: Date of Departure from Country *
Country #4: Please List all Cities and Dates you will be in each City *
DESTINATION #4: Date of Arrival in Country *
DESTINATION #4: Date of Departure from Country *
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 .doc, .docx, .pdf, .bmp, .gif, .jpeg, .jpg, .png, .psd, or .tiff with a maximum size of 10 MB.
Flight Itinerary (Optional) Please upload a file with the extension .doc, .docx, .pdf, .bmp, .gif, .jpeg, .jpg, .png, .psd, .tiff, .xls, or .xlsx with a maximum size of 10 MB.
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