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Student Accident Insurance Application

This document is an application form for the University of Trinidad and Tobago's Students Group Personal Accident Insurance. It requires personal details of the student, including their identification number, programme name, date of birth, and beneficiary information. The applicant acknowledges that coverage is limited to accidents occurring during UTT sanctioned activities.

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edenjohn13578
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21 views1 page

Student Accident Insurance Application

This document is an application form for the University of Trinidad and Tobago's Students Group Personal Accident Insurance. It requires personal details of the student, including their identification number, programme name, date of birth, and beneficiary information. The applicant acknowledges that coverage is limited to accidents occurring during UTT sanctioned activities.

Uploaded by

edenjohn13578
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

STUDENTS GROUP PERSONAL ACCIDENT INSURANCE

APPLICATION FORM

Name of Student: …………………….……………………………………..……………………………


First Name Last Name

Student’s UTT Identification Number: …………………………………..………………………………

Programme Name: ………………………………………………………………………………………..

…………………………………………………… Enrolment Date: ………………………


(Year/ Month/ Date)

Date of Birth: …………………………………… Gender: Male □ Female □


(Year/ Month/ Date)

Name of Beneficiary: …………………………………………………………….……………….…..…..


First Name Last Name

Relationship of Beneficiary: …………………………………………………………………………....…

I hereby apply for Coverage under The University of Trinidad and Tobago Students Group Personal
Accident Insurance as per the attached Benefit Schedule. I also acknowledge that coverage is limited to
accidents resulting from UTT sanctioned activities only.

……………………………………….. …………………………………….
Student’s Signature Date

FOR OFFICIAL USE

……………………………………………….. ……………………………………….
Plan Administrator Signature Date

STUD-FM-005 Revision Number: 0 Revision Date: 31-07-2014 Page 1 of 1

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