Request for Program Insurance

Page One

Information on the Program

Name of Activity, Event, or Program *This question is required. If your unit will be hosting similar activities, events, or programs, be sure to name them differently.

Sponsoring Unit or Department *This question is required.

Choose the type of activities that will be taking place. *This question is required.

Day or Classroom Activities Only
Adventure Sports Activities
Overnight or Any Upward Bound Program Activities
Sports Activities

Dates of Activity *This question is required.

Estimated Number of Participants *This question is required. This question requires a valid number format.

Budget Number *This question is required.

Activity Code (if applicable)

Director of the Program

Program Director First Name *This question is required.

Program Director Last Name *This question is required.

Program Director Phone *This question is required.

Department Head

Department Head First Name *This question is required.

Department Head Last Name *This question is required.

Department Head Phone *This question is required.

Request Completed By

Request By First Name *This question is required.

Request By Last Name *This question is required.

Request By Email *This question is required.

Request By Phone *This question is required.

Policy Statements

Check each statement to acknowledge your understanding of Risk Management policies for Camp Insurance *This question is required.

Space Cell	Acknowledged
Requests without valid budget number will not be processed *This question is required	Acknowledged
Completed Activity Reports are due within two weeks after camp or activity is completed *This question is required	Acknowledged
Departments will be charged according to estimated number of participants if the Completed Activity Report is not turned in on time. *This question is required	Acknowledged
Our program director is aware of the obligation to obtain a signed Agreement to Participate (waiver of liability) form from each participant. *This question is required	Acknowledged
A participant who does not have a waiver on file in the program office will not be eligible to participant in any activity. *This question is required	Acknowledged

Reminder: Payments to American Income Life are due within 14 days of camp completion.