5 UCL COMPULSORY HEALTH INSURANCE PACK IF YOU HAVE

5 UCL COMPULSORY HEALTH INSURANCE PACK IF YOU HAVE
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UCL Compulsory Health Insurance Pack

If you have purchased compulsory health insurance from your host institution, please complete this pack. Once your pack has been completed fully, you must email this to [email protected]

What is included in this pack:

Page	Form	Notes
Page 1	Student Details	You are to complete this fully.
Page 2	UK Bank Account Details Form.	Only complete this form if you would like to receive your reimbursement by bank transfer (can only be into a UK bank account). See below if you do not want this to be reimbursed by bank transfer.
Page 3	Cheque Payment	You are to complete this form ONLY if you would like to be reimbursed by cheque. Please remove this page if you would like to be paid by bank transfer.
Page 4	Screen shot of proof of health insurance coverage amount	You must complete this.

Student Details

First Name
Surname
UCL Student Number

How would you like to be reimbursed? Tick one:

5 UCL COMPULSORY HEALTH INSURANCE PACK IF YOU HAVE

Cheque (Go directly to page 3, print, complete and submit pages 1, 5 & 6 to the Study Abroad Team)

5 UCL COMPULSORY HEALTH INSURANCE PACK IF YOU HAVE

UK Bank Account Transfer (Print, complete and submit pages 1, 3 & 6 to the Study Abroad Team).

Please note that a reimbursement by bank can only be transferred if it is a UK bank account.

Please ensure that the details you have written here are correct. If any details are incorrect, this will cause a delay in receiving your reimbursement.

BANK ACCOUNT DETAILS FORM

PLEASE COMPLETE IN BLOCK CAPITALS and return to the Study Abroad Office

Student Name: UCL Degree Programme:

________________________________________________________________________________

Bank Name: Bank Branch:

_______________________________________________________________________________

Bank Address: Bank Sort Code:

________________________________________________________________________________

Bank Account Number:

________________________________________________________________________________

Bank Postcode: Name as it appears on Account (e.g. Mr S Abroad)

________________________________________________________________________________

UCL email address:

NOTES

By completing this form the student is confirming that they wish their payment to be paid by electronic transfer directly to the above bank account. It is the responsibility of the student to ensure the details provided are accurate.

The student understands that, once they have submitted this form, it may not be possible for UCL to arrange for subsequent payments to be made by a different payment method (e.g. cheque).

The student understands that if the information required within the Health Insurance Reimbursement pack is not completed sufficiently, it will not be processed.

Signature……………………………………………… Date……………………………………

(signature must be handwritten – not typed)

For completion by the Study Abroad Office

UPI Number………………………………….. Site Address: SAO

Authorised By………………………………… Date…………………………………………

For completion by UCL Finance Division

Supplier Set up.………………………………. Supplier Site Set up…………………………

Bank A/C Assigned………………………….. Switched to BACS………………………….

Cheque Reimbursement

If you would prefer to be reimbursed by cheque instead of a bank transfer, you must complete this page.

If you would like to be reimbursed by bank transfer and completed the UK Bank Account Details Form in this pack, please skip this page.

Please complete the table below.

Full Name

COMPLETE IN BLOCK CAPITALS

Postal address where the cheque should be sent to

COMPLETE IN BLOCK CAPITALS

N.B: It can take slightly longer to receive a cheque than bank transfer due to postal services.

Proof of Payment

Please copy and paste a screen shot of your proof of payment on this page and subsequent pages if needed. Please refer to the Insurance section at www.ucl.ac.uk/studyabroad/insurance for details on what is accepted as proof of payment. If you do not meet those requirements, your reimbursement request will be denied.

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Tags: compulsory health, purchased compulsory, compulsory, insurance, health