Travel Health Insurance for Resident Physicians

THIS FORM IS ONLY FOR UNC RESIDENTS AND FELLOWS ONLY!! Residents are required to purchase travel health insurance through UNC School of Medicine if their travel is related in any way to their medical training. Please note: the cost of Travel Health Insurance has increased. For the 2011-2012 the coverage will cost $1.32 per day.

Today's Date

Year / Month / Day Hour : Minute AM/PM

Last Name

First Name

Middle Name

Your UNC email address example "shawes@unch.unc.edu"

Date of Birth

Year / Month / Day Hour : Minute AM/PM

Gender

Male
Female

Year of Training e.g. PGY1, PGY2, PGY 3...

Residency Program e.g. Internal Medicine, Family Medicine, General Surgery...

Date of projected completion of ACGME program please enter month and year (06/2014 or 12/2015...)

Destination Country

Destination City or Region

Program Contact Information

Please enter the name, phone number, and email address of a contact (supervising physician preferred) located in the country you will be visiting.

Program Name For Example: UNC Project Malawi or Honduran Health Alliance. If your experience is not with an established program, you can give the name of a hospital or other description here.

Contact Name

Phone Number

Email Address

Website (if available)

Course Coverage

Beginning of Elective Period

Year / Month / Day

End of Elective Period

Year / Month / Day

Additional Coverage

Note: The maximum number of days of "Before/After" coverage is 7 days for each period. The minimum number of days of "Before/After" coverage is 2 days for each period. They cannot be combined at either end of your trip for the maximum 14 days. DO NOT OVERLAP days between Course Coverage and Additional Coverage.

Before Elective Period - Begin

Year / Month / Day

Before Elective Period - End

Year / Month / Day

After Elective Period - Begin

Year / Month / Day

After Elective Period - End

Year / Month / Day

Emergency Contact Information

Please enter the name of a person (family member, etc.) to contact in case of emergency.

Contact Name

Phone number

Email Address

Funding Sources

Were you funded for this experience?

Yes
No

How much money were you given?

Please list your funding source(s)

Confirmation By checking this box, you affirm that the information above is accurate, and that you are UNC resident or fellow. For the comments field: Please add the names and birth dates of any family members traveling with you (if applicable).

Comments (optional)

After submitting this form, you will receive an email stating the amount of money you will need to pay for travel insurance. You will need to pay online or drop off a check payable to "UNC School of Medicine" at the Office of International Affairs in 1066 Bondurant Hall. You will also receive an email giving you access to the GLBE999.MOD.1112 Sakai Site where you will find the two required modules and corresponding quizzes.