(Note: This form should be submitted at least 5 full working days prior to departure - fields marked * are required)

Name(s) of traveller(s)*:

Position (e.g. staff, postgraduate student, etc)*:

Nationality of traveller(s)*:

College/School/Institute/University Service Department*:

Ext. No*:

Contact email address*:

Email address for cover note*:

Please complete the following details for each trip.

Please note, if you are travelling to any of the following countries, a Disturbed Areas Questionnaire must be completed (see main travel insurance page for link to form) -

Colombia, Iraq, Mexico, Nigeria, Philippines, Venexuela, Yemen, Afghanistan, Chechnya, Somalia or North Korea.

Purpose of travel (if conference involved, please provide title of conference)*:

Is insurance cover note required for visa application purposes? *
please select... yes no

Will any part of the trip involve holidays? *
please select... yes no

If yes, please provide dates & details in box below *
If no, please enter n/a in box below *

Information on hazardous activities:
(if applicable)

Pre-existing medical conditions

Have you been advised against travelling by a doctor or consultant? *
please select... yes no

If yes, then the Insurance Section will contact you for further information.

Any other relevant information relating to your trip