Request for Group Accident Insurance Coverage

This request must be received by Risk Management prior to the departure date for the insurance to be in effect. Please complete and submit. A confirmation number will be issued via email.

If you have any questions or concerns, please call 277-9790 or email us at riskmgt@unm.edu.

Department Name:
Organization Code:
Authorizing Person:
Accountant's Email:
Accounting Contact Name:
Accounting Contact Number:
Charge Index No.:
Percent or Amount to Index:
Charge Index No.:
Percent or Amount to Index:
Trip Destination and Activities:
Travel Begin Date: (e.g. 01/01/2001)
Travel End Date: (e.g. 01/01/2001)
Days of Travel:
Cost of Travel: $
No. of Participants:

Participant's Information

Name DOB or Banner ID Number