CANTERBURY CHRIST CHURCH UNIVERSITY
No.
For University Use Only
STUDENT TRAVEL INSURANCE REQUEST
PLEASE COMPLETE IN BLOCK CAPITALS AND RETURN ELECTRONICALLY TO THE
UNIVERSITY INSURANCE OFFICER (UNIVERSITY SOLICITOR’S OFFICE) VIA WEB SITE
INSURANCE.ENQUIRIES@CANTERBURY.AC.UK PREFERABLY AT LEAST 10 DAYS
BEFORE DEPARTURE.
DEGREE OR COURSE
BEING
UNDERTAKEN:
REASON
FOR
TRAVEL:
(i.e. work placement, Field
Trip etc)
COUNTRY &
AIRPORT/
EUROSTAR STATION
OF DESTINATION:
(PLEASE STATE IF RETURN JOURNEY IS FROM A DIFFERENT AIRPORT)
STOPOVERS
PLANNED
IN OTHER
COUNTRIES OR
STATES:
DATE
DEPARTURE:
OF
DATE OF
RETURN
TO UK
AIRLINE, FLIGHT Nos.
AIRPORTS
(INCLUDING
INTERNAL FLIGHTS)
IF ANY ADDITIONAL
HOLIDAY/
PERSONAL TRAVEL
INVOLVED PLEASE
ADVISE INCLUDING
ANY
SPORT/HAZARDOUS
ACTIVITIES
PLANNED
(MAXIMUM OF 7 DAYS – LOCATION/COUNTRY)
DATE OF BIRTH
PERSON
TRAVELLING:
(Full name as per
Passport)
UK PASSPORT
YES/NO
NATIONALITY
CAMPUS
STUDENT ID
1
CANTERBURY CHRIST CHURCH UNIVERSITY
STUDENT TRAVEL INSURANCE REQUEST
No.
For University Use Only
NUMBER
FACULTY
Tutor Name
PLEASE NOTE: THAT INSURERS SHALL NOT BE LIABLE FOR ANY CLAIM WHERE AN
INDIVIDUAL IS TRAVELLING AGAINST THE ADVICE OF A QUALIFIED MEDICAL
PRACTIONER OR FOR THE PURPOSE OF OBTAINING MEDICAL TREATMENT OR
MEDICAL ADVICE.
BRIEF DETAILS OF
ITINERARY :
HOTELS NAME, TEL NO.
SCHOOLS,
COLLEGES,
UNIVERSITIES BEING
VISITED
EMPLOYERS NAME
AND ADDRESS (IF ON
WORK PLACEMENT)
DETAILS OF ANY
LOANED
UNIVERSITY
EQUIPMENT YOU
PLAN TO TAKE WITH
YOU (IE.LAPTOPS,
CAMERAS &
RECORDING
EQUIPMENT,
MUSICAL
INSTRUMENTS).
MAKE, MODEL
(THIS EQUIPMENT SHOULD BE CARRIED IN YOUR HAND LUGGAGE )
YOUR EMERGENCY
CONTACT MOBILE
No.
PERSON
TRAVELLING
PERSONAL E-MAIL
(EMERGENCIES
ONLY)
NEXT OF KIN NAME
& CONTACT
TELEPHONE
NUMBER
(INC.
INTERNATIONAL
CODE IF
APPROPRIATE)
PLEASE NOTE: THAT UNLESS A CLAIM IS MADE THIS SECTION CONTAINING
2
CANTERBURY CHRIST CHURCH UNIVERSITY
STUDENT TRAVEL INSURANCE REQUEST
No.
For University Use Only
PERSONAL INFORMATION WILL BE DESTROYED AFTER YOUR RETURN TO THE UK.
PLEASE NOTE: YOUR CONFIRMATION OF TRAVEL INSURANCE DOCUMENT
AND EMERGENCY ASSISTANCE CARD NOTICE WILL BE SENT TO YOU
ELECTRONICALLY. SUMMARY POLICY COVER WORDING CAN BE
DOWNLOADED
FROM UNIVERSITY SOLICITORS OFFICE WEB PAGE, INSURANCE, STUDENT
TRAVEL
3