Sponsored Field Trip Reporting Form

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Use this form to report University-sponsored field trips and/or to secure accident insurance for your trip. NOTE: You do not need to submit a field trip roster to Risk Management, however, it is your responsibility to maintain a roster of all individuals attending a trip.

If you elect for your department to purchase the accident insurance for your trip, the policy provides medical benefits (up to $5,000 per Insured) to participants and chaperones for injuries sustained while on a trip sponsored by UNCC.

Insurance Premium Information
Length of Trip (in days) Premium Per Person
1 $0.67
2 $1.08
3 $1.39
4 $1.66
5 $2.02
6 $2.27
7 $2.52
8 $2.76
9 $2.99
10 $3.24

Email *

Trip Sponsor Full Name *

Trip Sponsor Email Address *

Trip Sponsor Organization/Department *

Departure Date *

YYYY

Return Date *

YYYY

Total Number of Days *

City/State Visited *

Place(s) Visited *

Purpose of the Trip *

Number of UNCC Employees Attending *

Number of UNCC Students Attending *

Number of Visitors Attending *

Do you want to purchase accident insurance for this trip? *

Do you want the University to purchase accident insurance for this trip on behalf of your department? Insurance information is above.

Yes

If "Yes" to insurance, please provide a fund number

Please provide the fund number to which we can allocate the premium for this trip. NOTE: Please use operating fund numbers only (do not provide a grant fund number). Insurance cannot be placed without a viable fund number. Premiums are invoiced in November of each year.

A copy of your responses will be emailed to the address you provided.

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