Fillable Printable Blank Travel Insurance Claim Form
Fillable Printable Blank Travel Insurance Claim Form
Blank Travel Insurance Claim Form
Page 1
Effective 28 July 2011
This travel insurance is arranged and managed by AGA Assistance Australia Pty Ltd
trading as Allianz Global Assistance (Allianz Global Assistance) ABN 52 097 227 177,
AFSL 245631 and is underwritten by Allianz Australia Insurance Limited (Allianz)
ABN 15 000 122 850, AFSL 234708.
Allianz Global Assistance is authorised by Allianz to enter into and arrange the policy and
deal with and settle any claims under it, as an agent of Allianz, not as your agent.
Email: [email protected]
Phone: 1300 725 154
Facsimile: (07) 3305 7016
Postal Address:
Travel Claims Department
Locked Bag 3038
Toowong DC QLD 4066
Australia
TRAVEL INSURANCE CLAIM FORM
Claim No:
PRIVACY We (Allianz and our agent AGA Assistance Australia Pty Ltd trading as Allianz Global Assistance) collect, use, and disclose your personal information (including sensitive
information) so that we can arrange, manage, and administer the travel insurance services (including any claims) according to our contract with you. We may disclose it to third parties
who assist us carry out these functions and processes. Please see our privacy notice in your Product Disclosure Statement or contact us on 1300 725 154 for a copy. Our corporate privacy
policy is also available at www.allianz-assistance.com.au
INTERNAL DISPUTE RESOLUTION Disputes are not an everyday occurrence, however, Allianz Global Assistance provides an internal dispute resolution process should any dispute arise. Please feel
free to ask for details. If you are not satised with the outcome of this process, we will advise you how to contact the insurance industry’s external independent complaints scheme.
FRAUD Insurance fraud places additional costs on honest policyholders. Fraudulent claims force insurance premiums to rise. We encourage the community to assist in the prevention
of insurance fraud. You can help by reporting insurance fraud. All information will be treated as condential and protected to the full extent under law. Report insurance fraud by
calling 1800 453 937.
STEP 1 – CLAIM FORM COMPLETION REQUIREMENTS
• Please read this claim form carefully and complete ALL steps outlined on this form, including the Declaration on page 7.
• Please use block letters.
• Please retain a copy of ALL documents for your records.
• Documents in a foreign language are required to be translated into English at your own expense.
• The claim form and ALL supporting documentation may be mailed, emailed or faxed to us. Please note: We reserve the right to request the original
receipts, reports or any other documentation be submitted in order to substantiate the claim.
• Please refer to the specied documentation requirements that you will need to provide when lodging your claim. As each claim is unique, further information
may be requested by us.
• AcopyofyourCerticateofInsurancemustbesuppliedwithyourclaim.
• Ifanypartofyourclaimisofadishonestorfraudulentnature,thenyourclaimwillbedeniedandwillbereferredtotheappropriateauthorities.
STEP 2 – CLAIMANT DETAILS
Policy and Claimant Details
ALL QUESTIONS IN THIS SECTION MUST BE ANSWERED
Name of Policyholder(s)
Name of Claimant (Mr/Mrs/Miss/Ms)
Certicate of Insurance/Policy Number
Address
Postcode
Telephone Home
Business
Mobile
Email Address
Date of Birth
/ /
Occupation
Travel Agent
Date of Booking Travel Arrangements
/ /
Date of Departure
/ /
Date of Return
/ /
Ifyouwishtogiveauthorityforanotherpersontoactonyourbehalfinrespecttothisclaimyoumustcompletethefollowingdetails(otherwisewe
willnotbeabletogiveanyinformationaboutyourclaimtoanyotherperson).
I/We, authorise (Name)
of (Address)
Postcode
Phone
Mobile
to act on our behalf in respect to this claim and to be provided with information relating to the claim.
Page 2
A. Previous Travel Claims History
Have you made previous travel insurance claims? Yes
No
If Yes, please complete table below. If No, please go to next step.
Date of Claim Name of Insurer Claim Number Details of Claim
Amount
Claimed
Amount Paid
B. Travel Arrangements
1. Did you use a credit card to purchase your travel (eg. ights, accomodation, tours)? Yes
No
2. If Yes, please complete the following: Name on Credit Card
Name of Financial Institution
Card Type: Visa
Mastercard
Diners
Amex
Card Level: Gold
Platinum
Other
STEP 3 – CLAIM INFORMATION
In this Section we will ask you the circumstances of your claim and the amount that you are claiming. Please tick the applicable box(s) relating to your claim and
answer the corresponding Section.
A. Overseas Medical, Dental and/or Hospitalisation Expenses Claim – please see below
B. Cancellation Charges/Loss of Deposit Claim (Cancellation of Pre-paid Arrangements) – please go to page 3
C. Additional Expenses Claim (Additional Travel or Accommodation Expenses) – please go to page 3
D. Luggage and Personal Effects Claim – please go to page 4
E. Rental Vehicle Excess Claim – please go to page 5
F. Delayed Luggage Expenses Claim – please go to page 5
G. Other – please go to page 6
Pleaseanswerallquestionsrelatingtowhatisbeingclaimed,otherwisewewillbeunabletoprocessyourclaim.
A. Overseas Medical, Dental and/or Hospitalisation Claim
THE FOLLOWING ITEMS MUST BE INCLUDED WITH THIS CLAIM*
1. Copy of your Certicate of Insurance.
2. Medical/Hospital/Dental Report detailing Treatment and Diagnosis.
3. Itemised accounts giving a breakdown and description of costs claimed, together with receipts if any accounts have been paid by you.
4. Completed Medical Certicate (see last page of claim form).
* Failure to provide these documents may result in delays in processing your claim.
Type of Injury or Sickness
Date of Accident or Commencement of Sickness
/ /
If injury - Give full details of Accident
Date of First Medical/Dental Consultation
/ /
Name of Doctor, Dentist and/or Hospital
Details of other treatment by Doctor, Dentist and/or Hospital
Dates in Hospital - Admitted
/ /
am/pm Discharged
/ /
am/pm
Did you contact our Emergency Assistance department? Yes
No
Have you ever suffered from the same or similar injury or sickness in the past? Yes
No
If Yes, give details including dates, names and addresses of treating physicians
Name and Address of usual family doctor
Please list each receipt/bill separately in the table below. Claims will be converted to Australian dollars using the currency rate applicable at the date and time the
expenses were incurred.
Name of Doctor/Dentist/Pharmacy/
Hospital or Provider
Treatment Performed
Date of
Treatment
Amount Charged
(StateCurrency)
Paid Yes/No
Refund
from Health
Funds
e.g. Doctor R Smith e.g. Consultation e.g. 10/02/07 e.g. EUR 100 e.g. Yes e.g. EUR 75
Page 3
B. Cancellation Charges / Loss of Deposit Claim
THE FOLLOWING ITEMS MUST BE INCLUDED WITH THIS CLAIM*
1. Copy of your Certicate of Insurance.
2. Copy of original Itinerary.
3. Terms and Conditions issued by Travel Agent and/or Transport, Tour or Accommodation Provider.
4. Letter from Travel Agent or, where travel was not arranged through a Travel Agent, a letter from the relevant organisation through whom travel was booked,
conrming payments made, refunds given and any amounts you are out of pocket.
5. Proof of payment for trip (ie. receipts, credit card/bank statements showing payments made).
6. If travel was cancelled due to Medical Reasons/Death - completed Medical Certicate (see last page of claim form) and copy of Death Certicate (if applicable).
7. If travel was cancelled by a Transport Provider - letter from them explaining the circumstances of the cancellation and any refund/compensation paid or payable to you.
* Failure to provide this documentation may result in delays in processing your claim.
What was the reason why you could not commence or complete your proposed Journey?
Was your Journey cancelled as a result of Injury/Sickness to yourself? Yes
No
Was your Journey cancelled as a result of Injury/Sickness to any other person? Yes
No
If Yes, please provide
Full Name
Date of Birth
/ /
Address
Relationship
Nature of Injury/Sickness
Date your Journey was booked:
/ /
Date your Journey was cancelled
/ /
Details of Journey
Date Description of Booking Supplier Amount Paid
Refund
Received
Amount
Claimed
C. Additional Expenses Claim
THE FOLLOWING ITEMS MUST BE INCLUDED WITH THIS CLAIM*
1. Copy of your Certicate of Insurance.
2. Copy of orginal Itinerary.
3. Receipts, bank/credit card statements showing amounts paid by you for original Itinerary.
4. Proof of payment for additional expenses claimed (ie. tax invoices, receipts, credit card/bank statements showing payments made).
5. If the additional expenses were incurred due to the unfortunate event of a death - a copy of the Death Certicate.
6. If the additional expenses were incurred due to a Transport Provider - letter from them explaining circumstances and any compensation paid to you.
* Failure to provide these documents may result in delays in processing your claim.
Please state the reason/event that caused the additional expenses being incurred
What was the unexpected expense incurred?
Please list each receipt/bill separately in the table below. Claims will be converted to Australian dollars using the currency rate applicable at the date and time the
expenses were incurred.
Date of Expense Description of Expense Amount Date of Original Plan Description of Original Cost Amount
e.g. 24/07/07 e.g. Hotel in Paris e.g. EUR 100 e.g. 24/07/07 Flight to Munich e.g. EUR 75
Page 4
D. Luggage and Personal Effects Claim
THE FOLLOWING ITEMS MUST BE INCLUDED WITH THIS CLAIM*
1. Copy of your Certicate of Insurance.
2. Proof of ownership of the items claimed (ie. tax invoices, receipts, or credit card/bank statements proving purchase of the item/s).
3. Report made to the Transport Provider/ Police/Hotel or other appropriate Authority.
* Failure to provide these documents may result in delays in processing your claim.
Give full details of how losses, damage or thefts occurred: (Detail each event)
Date loss/damage occurred
/ /
Time
am/pm Location/Country
Date loss/damage reported
/ /
Time
am/pm Location/Country
Loss/damage reported to - (Police, Airline or other Authority) Name
Were items lost/damaged by Carrier? (e.g. Airline) Yes £ No £ Name
Have you lodged a claim or complaint against any Carrier/Airline or other Authority or against any individual responsible for the loss or damage to your property? If
Yes, please provide details in the table below and attach copies of correspondence. If No, you should proceed to claim with your Carrier/Airline before submitting
your claim to Allianz Global Assistance.
NOTE:The1999MontrealConventionimposesaliabilityuponAirlinesandyoushouldclaimfromthemrst.
Carrier Claim no.
What action was taken to recover lost items?
Are any of the items covered by other insurance? Yes
No
If Yes - Which company
Policy Number
Were all the missing articles owned by you? Yes
No
If not, give details
Full Details of Articles Claimed
Store From Where Item
Was Originally Purchased
Original
Date of
Purchase
Original
Purchase
Price
Amount
Claimed
(AUD)
Proof of
Purchase
Attached?
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E. Rental Vehicle Excess Claim
THE FOLLOWING ITEMS MUST BE INCLUDED WITH THIS CLAIM
1. Copy of your Certicate of Insurance.
2. Copy of your Rental Vehicle Agreement.
3. Copy of the Repair Invoice if claim is due to the Rental Vehicle being damaged.
4. Copy of documents showing amount debited to you by Rental Vehicle company for damage/excess.
5. Report made to the Police or other appropriate Authority.
Date and time of accident/incident
/ /
Location of accident/incident
Rental Vehicle company name Country where the vehicle was rented:
Please state in full, exactly what happened for the claim to arise (if necessary, a diagram may be used to depict the event):
Was the damage due to a collision with another vehicle? Yes
No
If Yes, please provide the name and address of the person who was driving the other vehicle involved in the collision
Please provide the registration number of the other vehicle
Please provide the name and address of the insurer of the other vehicle:
Did police attend the incident? Yes
No
Was the accident/incident your fault? Yes
No
Repair costs Date the damage was paid for
/ /
Excess you were liable to pay Amount you are claiming for
Have you received compensation from any person or party involved in the accident or incident: Yes
No
If Yes, please state the amount received
F. Delayed Luggage Expenses Claim
THE FOLLOWING ITEMS MUST BE INCLUDED WITH THIS CLAIM*
1. Copy of your Certicate of Insurance.
2. Itemised receipts for the purchase of Essential Items claimed by you.
3. Property Irregularity Report from the Carrier (ie. bus line, airline, shipping line or rail authority) and conrmation of any compensation paid to you.
4. Ticket and Baggage Tags from the Carrier who caused your luggage to be delayed.
* Failure to provide these documents may result in delays in processing your claim.
Name of Carrier who delayed your luggage
Your arrival date
/ /
Your arrival time
am/pm
Date that your luggage was returned to you
/ /
Time of return am/pm
What compensation was received from the carrier?
Please complete the below schedule in full. Claims will be converted to Australian dollars using the currency rate applicable at the date and time the expenses
were incurred.
Description Of Essential
Items Purchased
Date of
Purchase
Price Paid
Store Where
Item Was Purchased
Receipt
Attached
Yes/No
e.g. Woollen Jumper e.g. 10/02/05 e.g. EUR 100 e.g. Benetton of London e.g. Yes
Page 6
G. Other
THE FOLLOWING DOCUMENTS MUST BE INCLUDED WITH THIS CLAIM
1. Copy of your Certicate of Insurance.
2. Any other information in support of this claim.
Please tell us in as much detail as possible what happened to you in order for you to make this claim. Be as specic as possible, including dates and amounts
paid. If there is not enough room in the space provided, you may continue your description of the events on a separate piece of paper.
Which Policy Benet Section(s) do you believe to be the most applicable under which you can make this claim?
STEP 4 - PAYMENT DETAILS
Provide your bank details below for a direct credit to your nominated bank account. Pleasenotewecannotdepositintoacreditcardaccount.
If we are required to make a payment on your behalf no payment will be made until we receive payment, from you, of any applicable excess.
Name of Bank
Branch:
Account Holder
BSB Number:
–
Account Number:
GSTINFORMATION(ONLYAPPLIESIFYOURPOLICYWASPURCHASEDFORABUSINESS).
Are you registered for GST Purposes? Yes
No
What is your Australian Business Number (ABN)?
Have you claimed or are you entitled to claim an Input Tax Credit (ITC) in respect to the GST paid on the insurance policy under which this
claim is being made? Yes
No
IF YES, what percentage of the GST did you claim or are you entitled to claim?
%
(if the GST paid and your ITC entitlement are the same amount, the answer to this question is 100%)
CUSTOMER SERVICE QUESTIONNAIRE In order to ensure that the services we provide are maintained to the highest standards, we would appreciate
a few moments of your time to complete a questionnaire. This will enable us to monitor our performance and implement any services which we feel
would benet our customers further. PleaseconrmthatyouagreetoreceiveaQuestionnairebyEmail £ (PleaseTick)
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MEDICAL AUTHORITY AND DECLARATION
I DECLARE THAT:
• I will use my best endeavours and render all reasonable assistance and co-operation to Allianz Global Assistance in the assessment of
my claim;
• The information supplied by me is true and correct and I have not withheld any information likely to affect the assessment of my claim;
• I understand that the claim may be denied if the information supplied is untrue, or I have not revealed all relevant facts;
• I understand that by investigating my claim or by accepting proofs of my claim, Allianz Global Assistance has made no acceptance of liability,
nor waived any of its rights in defence of any claim arising under the policy;
• A photocopy of this Authorisation shall be considered as effective and valid as the original and I specically authorise its use as such.
I appoint Allianz Global Assistance to do everything necessary or expedient to:
• give effect to the transactions contemplated by the authorisations described; and
• execute and deliver any other documents or do any other acts referred to in the transactions described.
I authorise any person, corporation, institution, private or government organisation, whether named by me or not, to provide such information
as Allianz Global Assistance in its absolute discretion considers relevant for its assessment of initial or ongoing benets for my claim including,
without limitation:
• all medical, surgical or other information concerning myself, my medical history, any treatment received by me and any medication taken or
prescribed for me (at any time);
• my Health Insurance claims history, including Medicare;
• any information in relation to my assets, liabilities, earnings, salary or wages (at any time);
• any information from third persons who may have information relevant to my eligibility to receive a benet, or my entitlement to receive an
ongoing benet.
Signature of Claimant
Date
Name of Claimant
Signature of Witness
Date
Name of Witness
/ /
/ /
Page 8
MEDICAL CERTIFICATE
To be completed by the patient’s usual Doctor/Dentist (at the claimant’s expense) in all cases of cancellation and medical claims resulting from accident, sickness or death.
Nameofpersontowhomthiscerticateapplies(i.e.thepersonwhosestateofhealthcausedtheclaim):
Date of Birth
/ /
Address
Postcode
Instructions to the Medical Professional:
Please complete this form in block letters, and provide as much information as possible, as this will accelerate this Travel Insurance claim.
1. (a) Are you the patient’s usual medical practitioner? Yes
No
If Yes, for how long?
(b) If No, do you have access to their medical records? Yes
No
Theclaimantmustindicate(bytickingtherelevantbox)whichisapplicable,question2or3.
£ 2. Alteration to/cancellation of travel arrangements prior to travel.
(a)Did you recommend that travel be cancelled or postponed due to the patient’s state of health? Yes
No
(b) On what date did you make this recommendation?
/ /
(c)Please give precise details of the nature of the sickness or injury which gave rise to this recommendation (including the nal diagnosis)
(d) Did you fully explain the risk of travelling with this medical condition? Yes
No
(e) On what date did the patient rst become aware of their symptoms?
/ /
(f) Please describe the symptoms advised by the patient.
(g)On what date were you rst made aware of the condition, or change in the condition?
/ /
(h) Has the patient previously been investigated, diagnosed or treated in respect to the same/similar/related sickness or injury? Yes
No
If Yes, please attach copies of all letters from referred specialists, including the patient’s full medical history, current medications, all hospitalisations
and emergency department visits in the last two (2) years.
(i) Did the patient make the travel arrangements against your advice (or the advice of another medical practitioner)? Yes
No
OR
£ 3. Treatment costs/ additional expenses incurred during travel.
(a)What do you understand to be the sickness or injury which resulted in the need to seek medical care/ interrupt the patient’s travel plans?
(b) Has the patient previously been investigated, diagnosed or treated in respect to the same/similar/related sickness or injury? Yes
No
If Yes, please attach copies of all letters from referred specialists, including the patient’s full medical history, current medications, all hospitalisations
and emergency department visits in the last two (2) years.
(c)Was there any indication that medical care may be required on the journey?
(d) Was the patient non-compliant with medical advice whilst on the journey? Yes
No
(e) Did the patient travel against your advice (or the advice of another medical professional)? Yes
No
IcertifythatthestatementscontainedinthisMedicalCerticatearetrueandcorrect.
Doctor’s Signature
Date
/ /
Doctor’s Stamp
Please post this form together with your claim form and all supporting documentation to Travel Claims Department, Locked Bag 3038, Toowong DC QLD 4066 Australia
PLEASE NOTE: We cannot process your claim if you do not supply the listed documentation with your fully completed and signed claim form.
Claim No:
Policy No:
Email: [email protected]
