southernillinois.edu/risk-management/medicalbenefitform.shtml

Name of Program/Camp

Date Submitted

MonthDayYear

Program/Camp Director

Sponsoring Department

Mail Code or Mail Box

Requester's Name*

Requester's Phone*

Requester's E-mail*

Beginning Date of Program/Camp

MonthDayYear

Ending Date

MonthDayYear

Number of Days to be Covered

Number of Participants to be Covered

List of Participants

If more than 25 participants, or list is not finalized, please fax a list to (618)453-5442 or e-mail it to riskmgmt@siu.edu. This listing must be received no later than the first day of camp.

Number of Counselors Covered

Covered individuals may not include SIU students, staff or faculty.

List of Counselors Covered (if any)

Account Title to be Billed

Budget Purpose Number*

Cannot be Trust and Agency Account, e.g. Foundation Account

Fiscal Officer Name

By submitting this form, you are authorizing University Risk Management to charge the above account for Excess Medical Benefit Insurance and you are affirming that all listed individuals are not SIU students, staff, or faculty and that this Program is funded solely by the University.

Please print a copy of your confirmation for your records.

Please verify that you are human*

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