Travel Insurance Application Form

TRAVEL INSURANCE APPLICATION FORM

TO BE USED FOR UNIVERSITY BUSINESS ONLY

NAME: / DEPT:
Please circle: Staff / Student / USUAL COUNTRY OF RESIDENCE:
COVER REQUIRED FROM: TO: NO. OF DAYS:
COUNTRY & PLACE TO BE VISITED:
(If more than one country, please give breakdown of dates:

All overseas activities carried out by staff and students are subject to a risk assessment. Exclusions to this requirement include individual staff related business, research or academic trips to known and safe locations and, where travel is a precursor to contracts or partnerships that will result in regular travel requirements

Unless the Foreign Office indicates there are no restrictions on travel, by signing this form you are confirming that a risk assessment (if required) has or will be completed prior to travel and/or the traveller is familiar with the requirements of the Health and Safety in Fieldwork (Off Campus) Policy.

All travellers should log on to the insurers Travel Guide website at

www.aig.co.uk/Travel-Assistance_3660_446294.html

which will provide the traveller with country risk information etc. before travelling.

This form must be accurately and fully completed and sent to the Finance Department at least one week before the date of departure to ensure that the trip is covered by the University’s Travel Insurance.

Insurance cover cannot be arranged retrospectively.

I certify that this trip is for the purpose of University business only.
Signature of traveller:
I confirm that this trip is for University business
Authorised by:
(Director or Head of Department)
(NOT the traveller) / Date: / PRINT NAME:

The completed form should be taken, posted or scanned to:

Lianne Bradford, Finance Department, Room 101, Gardiner Building

Email: Telephone extension: 68181

A Lifeline Plus Employee Travel Pack will be issued to each traveller. This should be kept for further use but please ensure that another form is completed and sent to the Finance Department before departure on further trips or insurance cover will not be in place.

Please tick here if a Travel Pack is required