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International Travel Justification & Pre-Notification Form
For travel to countries in Zones 1A and 1B
Employees of Williams-Sonoma, Inc. are covered by a Travel Accident Policy through Cigna. This policy
requires pre-notification or pre-authorization before travel to certain countries may be approved. These
requirements notwithstanding, Williams-Sonoma, Inc. reserves the right to approve or deny travel to these
countries based on the associate’s justification for the travel. Due to the potentially dangerous nature of these
countries, Williams-Sonoma, Inc. maintains a policy that associates travel to these countries only when
absolutely necessary to business needs and if there is no realistic alternate destination.
To be completed by associate requesting travel
Associate Name
Title
Desired Destination
Travel Dates
Begin _______/_______/_______ End _______/_______/_______
Purpose of Travel
Could this purpose be fulfilled by traveling to a location in Zones I - VI?
Fax this form to the Benefits Department at 415.439.1050 and email to the WSI Travel
Department at
WSI-Travel@wsgc.com.To be completed by Company
Primary Determination
Approved
Denied
Risk Management
Approved
Denied
Executive Committee Member
Notification to Cigna
N/A (Did not pass Primary Determination)
Yes
Date _____________
Benefits
Authorization received from Cigna
N/A (Not Zone IB country)
Yes
No
Date _____________
Benefits
ADDITIONAL NOTES: