Request for Group Accident Insurance

Request for Group Accident Insurance

*** Please note that Group Accident Insurance Requests must be submitted at least two (2) business days prior to the planned start of the trip for insurance purposes.

Requests for Group Accident Insurance cannot be guaranteed unless submitted to UNM Risk Services at least two (2) business days prior to the planned start date of the trip.

Please complete and submit the form, a request identification number will be issued via email after submission.

Authorized Person First Name*

Authorized Person Last Name*

Authorized Person Email*

Accountant First Name*

Accountant Last Name*

Accountant Email*

Department Name*

Select level 5 department.

Select or enter value

Trip Destination and Activities*

Enter trip destination and details of planned activities.

Index Code*

Enter your index code.

Travel Begin Date*

Enter begin date of travel.

Travel End Date*

Enter end date of travel.

Number Travel Days*

Enter total number of travel days.

Total Number Travelers*

Enter total number of travelers.

Traveler Names*

Enter name(s) of traveler(s). Please enter First Name and Last Name of all participants.

Ex. Jane Doe (Faculty), John Doe (Student)

Cost of Travel

Cost of travel is calculated at $1.00 for each traveler, for each travel day. A confirmation email will provide a summary of request information, including the total cost for the total number of travelers for the number of days of travel.

Example: (1 traveler), (3 travel days), (cost for each traveler for each travel day) = 1 x 3 x $1.00 = $3.00

Send me a copy of my responses

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