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Application for Travel Insurance Cover
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› Application for Travel Insurance Cover
Details
Name:
*
ID Number:
*
Email Address:
*
Department:
*
Status e.g. Staff, Undergraduate:
*
Work Address:
*
Country of Destination(s):
*
Departure Date: (dd mmm yyyy)
*
Return Date: (dd mmm yyyy)
*
Purpose of Trip:
*
- Please Select -
Conference (to attend or speak at)
Field Trip/Expedition
Research
Exchange/Language Student
Laboratory Work etc
Other (please provide additional information below)
Other (please specify):
Please provide full details about this trip:
*
If you are going on a field trip or an expedition is it particularly important that you provide full details of the nature, purpose and location of your fieldwork and the types of activities which will be undertaken.
Guidance notes on expeditions and field trips
.
Contact Address:
Complete this section if you are a exchange / language student
Health Declaration (for trips over 90 days):
If you require to take medication, please give details including dosage, frequency, condition being treated, how long medication has been required
If you suffer from epilepsy, how frequently do the fits occur:
Please give details of any health condition not covered above.
Equipment
University equipment is covered worldwide, but not while in transit (except up to the value of £25,000 within the UK) If you require separate cover on any equipment you are taking with you please
complete the Goods in Transit Cover Form
