On-line request form for Spouse/Children accompanying Staff/PhD/HDR Students on Business Travel

Family members are not automatically included on the University’s travel insurance policy, the University can extend the policy to include spouse and dependent children at an additional cost to yourself.

In order for Insurance to be able to provide you with a quote, can you please provide the following information.

Please note a request need to be sent to the Insurance Office at least 5 working days prior to travel date to allow time for processing of your request and placement of the appropriate insurance.

**Please ensure you have enabled the document. **

Staff Members Details:
First Name:	Click to enter text.	Surname:	Click to enter text.
Are you a PhD/HDR Student?	☐YES ☐ NO – (please check one)
Date of Birth:	Click to enter text.
Date your travel commences:	Click to enter text.	Date you arrive home:	Click to enter text.
Do you have a pre-existing medical condition that may require treatment while away	☐NO ☐ YES - please provide details below Click to enter text.
If you are adding any Personal travel, is this less than 20% of the total trip:	☐NO ☐ YES - please provide tick box below: ☐ 20% or Less ☐ 30% or 50% ☐ over 50%
Have to you received approval to have your spouse/children accompany you on University business travel:	☐NO ☐ YES - please provide details below: Click to enter text.
Will your spouse/children accompany you for the majority of your travel:	☐NO ☐ YES - please provide details below: Click to enter text.
Are your children a dependant*:	☐NO ☐ YES ☐ N/A *Dependent Children include step, foster, or legally adopted children who must be: unmarried, under 19 years old (or under 25 if a full-time student) and dependent on your support and maintenance.
Total number of travel days:	Click to enter text.
Accompanying Spouse/Children’s Details:
1. First Name:	Click to enter text.	Surname:	Click to enter text.
Date of Birth	Click to enter text.
2. First Name:	Click to enter text.	Surname:	Click to enter text.
Date of Birth	Click to enter text.
3. First Name:	Click to enter text.	Surname:	Click or tap here to enter text.
Date of Birth:	Click enter text.
Date your travel commences:	Click or tap here to enter text.	Date you arrive home:	Click to enter text.
Do any of your family members pre-existing medical condition that may require treatment or medication while travelling:	☐NO ☐ YES - please provide details below: Click to enter text.
Total number of travel days:	Click to enter text.
** Please only hit the ‘Submit’ button once. No pop up message will appear after submitting.