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. The coverage will cost $1.30 per day.

Today's Date
/ /  
Date of Birth  
/ /  
Gender  


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.
Course Coverage
Beginning of Elective Period  
/ /  
End of Elective Period  
/ /  
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 and the rate is $2.69 per day. They maximum number of "Before/After" days allowed is 15. DO NOT OVERLAP days between Course Coverage and Additional Coverage.
Before Elective Period - Begin
/ /  
Before Elective Period - End
/ /  
After Elective Period - Begin
/ /  
After Elective Period - End
/ /  
Emergency Contact Information
Please enter the name of a person (family member, etc.) to contact in case of emergency.
Funding Sources
Were you funded for this experience?  


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.