Travel Health Insurance Application Form

This form helps to sign you up for the University's international travel health insurance.

THE FORM IS FOR SCHOOL OF MEDICINE STUDENTS AND FACULTY ONLY!! If you are not in the School of Medicine, please contact the Study Abroad office for more details. IF YOU ARE A UNC PHYSICIAN RESIDENT, click here to access the resident form.

Students are required to purchase travel health insurance through UNC School of Medicine if they are receiving academic credit or funding from UNC, or if they are acting in the role of a medical student.  For example, students are required to purchase travel health insurance through UNC if they are participating in a program like Himalayan Health Exchange, Celas Maya, Child Family Health International , UNC Project Malawi, or any other program where the student is identified as a medical student – regardless of funding or academic credit. If none of these categories applies to you, you are ineligible for the special UNC rate at HTH, but can call them directly at the information below.

If you would like to have additional coverage beyond the maximum coverage dates stated below, you can contact the insurance provider, HTH, directly.

The current rates are as follows:

Full Coverage = $1.42 per day
Faculty/Staff Coverage = $2.95 per day

For more detailed information on costs, see the HTH rate sheet (being updated).

Today's Date  
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Date of Birth  
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Status   If you are a faculty member that is interested in coverage for your spouse and/or children traveling with you, please include the name and date of birth of each additional person in the comments section at the bottom of this form.

Course Coverage
Beginning of Course Period   "Course" means the official organized experience (including direct travel to and from the course), regardless of whether you're getting academic credit for the experience. These dates should encompass everything that is not personal or extra tourist travel.
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End of Course Period  
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Course Information
Are you going to register for elective credit?

Emergency Contact Information
Please enter the name of a person (family member, etc.) to contact in case of emergency.
Program Contact Information
Please enter the name, phone number, and email address of a contact (supervising physician or program contact preferred) located in the country you will be visiting. DO NOT, again, DO NOT LIST the student leader or the faculty advisor for your UNC student group (HHA, PPS). You may only list a UNC contact here if you are going to Malawi or another UNC site with full-time, in-country UNC faculty/staff.
Funding Sources
Were you funded for this experience?  

Next Steps

After submitting this form, you will receive an email (usually within 5-10 days) stating the amount of money you will need to pay for travel insurance.  You will need to pay online or drop off the check at the Office of International Affairs in 1066 Bondurant Hall.  You are also required to sign the Code of Conduct form,  register with the UNC Global Travel Registry and sign the imbedded Travel Waiver form. If you are a student, you will also receive an email giving you access to the GLBE999.MOD.1112 Sakai Site where you will find the two required travel modules and corresponding quizzes.

Once this form has been processed and you have completed all other requirements, you will be eligible to apply for credit for your overseas course.