Cross Brand Design Services(R) 5

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:

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