Fillable Printable Travel Insurance Claim Sample Form
Fillable Printable Travel Insurance Claim Sample Form
Travel Insurance Claim Sample Form
TRAVEL INSURANCE CLAIM FORM
CLAIM REFERENCE NO:
POLICY NO:
(1) PERSONAL PROPERTY/MONEY AND DOCUMENTS
Please complete this form and return it with relevant documentation to the address
above. Do not hesitate to call if you have any queries.
A. PERSONAL DETAILS
Full name (as per policy):
Date of birth: Occupation: Telephone:
B. INSURANCE DETAILS
Policy name:
Date trip booked: Travel date: From: To:
Name of Travel Agent:
Name of Tour Operator if any:
Hotel accomodation details resort Country:
C. PERSONAL PROPERTY, MONEY AND DOCUMENTS
Including Baggage Delay)
Date Of Loss/Damage: Place Of Loss/Damage:
Full Details/Circumstances:
Was The Loss /Damage Reported To The Police? Yes No
Date Of Loss /Damage Reported To The Airline? Yes No
If No, Please State Reason:
Date Of Loss /Damage Reported To The Tour Operator:
Is Your Property Also Covered Under Household Contents Insurance?
Yes No
If Yes, Please Give Details Below:
Details of items Date of Shop & town Purchase Amount Evidence For office
lost/ damaged purchase where purchased price claimed of value use ONLY
Please continue on a separate sheet if there is insufficient space. Please mark all documents
for your claim reference.
The following original documents must be sent with your claim for claim processing;
1. Your Safari Card
2. Your travel tickets
3. Police, Airline or Tour Operator report
4. Evidence of Ownership such as original receipts, valuations, credit card receipts
5. Any other relevant documentation to support your claim
6. Your original holiday/flight confirmation and/or receipt or deposit receipt
(II) CURTAILMENT/MISSED DEPARTURE TRAVEL DELAY/PERSONAL LIABILITY
A. CANCELLATION/LOSS OF DEPOSIT/CURTAILMENT
Reason for Cancellation or Curtailment:
(1) FOR CANCELLATION/LOSS OF DEPOSIT
Date Trip originally booked: Total Cost of holiday:
Date insurance purchased: Amount refunded:
Date trip cancelled: Amount claimed:
(2) FOR CURTAILMENT OF TRIP
Date Trip originally booked: Date of Incident causing Curtailment:
Date Insurance purchased: Actual Return Date:
Original Transport Method (Air/Ferry/Coach....):
Amounts claimed for Additional Expenses:
IF THE REASON FOR THE CLAIMS IS MEDICAL, A MEDICAL REPORT BY THE USUAL
DOCTOR OF THE PERSON WHOSE CONDITION GIVES RISE TO THE CLAIM MUST BE
SUBMITTED
B. MISSED DEPARTURE/TRAVEL DELAY
Reason for Delay or Missed Departure:
(1) FOR MISSED DEPARTURE
Point of Departure:
Date & Time of Planned Departure:
Transport Used (Air/Coach/Ferry, etc.):
Method Employed to Rejoin Trip:
Amount Claimed:
(2) FOR TRAVEL DELAY
Scheduled Date and Time of Departure:
Actual Date and Time of Departure:
Number of hours delay: Flight number: Airline Company:
C. PERSONAL LIABILITY
Address of holiday apartment/hotel:
Date and time of incident:
Full details of the incident:
The following original documents must be sent with your claim form for claim processing
1. Your Safari Card.
2. Your original holiday/ flight confirmation and/ or receipt or deposit receipt.
3. Your travel tickets.
4. Proof of cancellation, medical certificate redundancy notice, court summons, etc
5. Receipts for additional travel and/or accommodations expenses (if applicable)
6. Confirmation of cause of claim from carrier, breakdown organization or garage, etc
7. Confirmation from the carrier stating reason for delay including actual travel time .
8. Any other relevant documentation to support your claim.
(III) MEDICAL EXPENSES CLAIM SECTION
Please complete this form and return it with all relevant documentation to the above
address. Please do not hesitate to call if you have any queries
Date of treatment Expenses claimed Amounts claimed For office use only
MEDICAL AND EMERGENCY EXPENSES/HOSPITAL BENEFIT
Date of Injury/Onset of Illness: Place of Injury/Illness:
Details of Injury/Illness:
Circumstances of Accident (if applicable)
Have you suffered from the same/similar condition before? Yes No
If YES, please ask your usual doctor to complete the attached medical certificate.
PLEASE NOTE: Any charge made by a doctor for medical reports must be paid by the
claimant.
If hospitalized, please state:
Admission Date: Discharge Date:
The following documents must be sent with your claim form for claim processing
1. Your Safari Card
2. Your original holiday/flight confirmation and/or receipt or deposit receipt
3. A Doctor’s Report, stamped and dated.
4. Hospital, Doctor, Chemist, Dentist receipts for amounts claimed
5. Receipts for additional travel and/or accommodation expenses (if applicable)
6. Any other relevant documentation to support your claim
7. Confirmation from the carrier stating reason for delay including actual travel time
DECLARATION
I declare that to the best of my knowledge all particulars contained in this form are true
and correct.
Signed: Date:
