Insurance Request Form

Contact Details

Surname * (or Family Name)
First Name *
Staff/Student *	Staff Student Other
ID Number *
Area/Unit *
Phone Number *
e-Mail address *
	Please note: Staff and Students must use their official University email account. Not using this may delay a response to your request.

Request type *	Claim Evidence of Cover (Certificate) Policy change Input to a University document (e.g. policy, procedure, guidelines, forms etc) Coverage clarification Waiver (Note: DO NOT SIGN WAIVERS without advice first) Contract/Agreement/Tender/MOU etc. Other
Request details *
	Attach or upload relevant documents (PDF, Word, Outlook or Zip Files only). Please note: if you have more than three (3) documents that need to be uploaded, please create and upload all documents as a ZIP file.
Document 1
Document 2
Document 3
Date required *	Day Month Year
	Please note:As a general rule, requests will be responded to within two (2) working days. More complex request may take longer than two (2) business days. If you require a response within a shorter timeframe, please outline the reasons for the urgency.
Urgency
	Please note: to ensure you receive the most appropriate advice, this request will be provided to the University's Insurance Broker. To read UC's privacy policy, go to Privacy at UC.