Proof of Evacuation and Repatriation Coverage Request

Name and other information must be listed exactly as it appears in the passport.

Family Name/Surname * 🛈

First Name/Given Name * 🛈

Date of Birth * +

U.S. Phone Number *

UR School

University Email Address *

UR Affiliation *

UR Department

Reason for Travel *

Is your travel considered University-sponsored or supported? Your travel MUST be considered *UR sponsored or supported activity to qualify for this coverage.

*UR definition of sponsored or supported travel:
Academic or business travel undertaken by University of Rochester Faculty, Staff, or Students and, in the case of students and medical residents, developed, funded, or administered by the University of Rochester, or in the case of faculty/staff, related to the individual’s role at the University, or developed, funded, or administered by the University. Such travel may include, but is not limited to: teaching, research, conferences, administrative work, for-credit study, internships, field studies, service learning, volunteer or work programs and other experiential learning, performances, athletic competitions, and trips abroad in connection with student organizations recognized by any UR academic or administrative unit, and students in absentia.

*

Number of countries you intend to visit *

Country 1 *

Country 2 *

Country 3 *

Country 4 *

Country 5 *

Travel Start Date * +

Travel End Date * +

Enter the word in the image *
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NOTE: The Office for Global Engagement will send the completed certificate of coverage to your provided email within 3 business days.