Claim Number. Departure Date: From / / To / / Occupation Date of Birth / / Date of Booking Travel Arrangements Date of Departure Date of Return

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1 Savannah Insurance Agency Pty Ltd ABN Corporate Travel Claim Form Details of the Insured Insured Name (Traveller) Policy Number Claim Number IMPORTANT 1. Please complete the Policy Details Section and any of the following sections which relate to your claim. 2. Please ensure that this form is signed and that all questions are answered fully. 3. We may ask for details of your medical history or of the person whose injury, illness or death necessitated additional expenditure or the cancellation of the journey. Such information must be obtained at your expense. 4. To avoid delay in processing your claim please ensure that all necessary documentation specified in the section relevant to your claim is sent with this form. 5. Claims may be subject to an excluded period of claim as described in your Policy. 6. Please check that this form has been fully completed as any omissions may delay your claim. Name of Insured Company Traveller s relationship to Insured Company Did the loss occur whilst on Authorised Business Travel? Was an air trip involved in the travel? Details of Journey Departure Date: From / / To / / Return Date: Position Held Policy Details Section Claimant Name Surname (Traveller) (BLOCK LETTERS) Given Name(s) Postal Address State Postcode Occupation Date of Birth / / Contact Numbers Travel Agent Business Mobile Private Fax Telephone Date of Booking Travel Arrangements Date of Departure Date of Return Was this authorised business travel? Have you made previous claims for travel insurance? If Yes, please give details Name of Insurer Date of Claim Type of Claim Amount / / / / Are you registered for GST? What is your ABN? Have you claimed or intend to claim an input tax credit on the GST component of the premium applicable to the Policy? Are you entitled to claim an input tax credit for repairs or replacement of the item that has been lost or damaged? Will you be claiming an amount less than 100%? Specify amount claimed % Will you be claiming an amount less than 100%? Specify amount claimed % SAHF Page 1 SIA CTI-CF 0609

2 Claim Payment Details Electronic Funds Transfer For fast claim payments please provide your bank account details below: Name of Bank Account Name BSB Account Number Section E - Loss of Deposits and Charges Claims The following documents are required in support of your claim (Please tick ( ) when attached). Doctor s Certificate (see Page 5) Travel Agent s letter confirming details of tour costings and cancellation charges Transport provider s reports Reasons for Cancellation Date of Cancellation / / Where cancellation was due to accident, illness or death, please state the name of the person whose accident, illness or death necessitated the cancellation: Name Relationship to Insured Amount claimed for irrecoverable prepaid travel costs $ Section 2 - Luggage and Personal Effects and/or Money The following documents are required in support of your claim (Please tick ( ) when attached). Police or responsible authority s report Original purchase receipts/proof of ownership Quotation for repair of damage Transport provider s reports Date of Loss / Theft / Damage / / Time am/pm Location Country Please state exactly what happened: What action did you take to recover the lost articles? (If space is insufficient please attach details and a sketch if necessary). Which responsible authority (eg Police) was notified? Date notified / / Time am/pm SAHF Page 2 SIA CTI-CF 0609

3 Sections B & C - Medical Expenses and Additional Expenses Claims The following documents/statements are required in support of your claim (Please tick ( ) when attached). Original medical/hospital accounts detailing illness/medical condition Accounts in support of accommodation expenses Medical certificate supporting need for altered travel plans Copy of Travel Itinerary Date of accident, illness or circumstance / / Time am/pm Country Particulars of claim: If your claim arises from injury or illness please specify the nature of such injury or illness: Name of person whose injury or illness caused additional expenditure Their relationship to you Has the illness or injury occurred before? If Yes please supply the following details: Usual Doctor s Name: Doctor s Telephone No: Date of last visit: / / If additional expenses have been incurred as the result of an injury, illness or death of a person in Australia please state: Their relationship to you Expenditure for which reimbursement is claimed Provider (eg Doctor/Hospital etc) Service (ie Medical/Hospital etc) Amount Claimed Additional Expenses SAHF Page 3 SIA CTI-CF 0609

4 Medical Authority With regard to medical and/or additional expenses I hereby authorise any hospital, physician or other person who has attended or examined to me to furnish to Savannah Insurance Agency Pty Ltd or its representative any and all information in respect of treatment given for: A copy of this authorisation shall be considered as effective and valid as the original. Name of Usual Doctor Address of Usual Doctor State Postcode Medical Authority: I authorise any hospital, physician or other person who attended me, to give Savannah insurance Agency Pty Ltd or its representative any or all information with respect to any illness or injury, medical history, consultation, prescription, or treatment, and copies of all hospital or medical records. I also agree that copies of all employer records including verification of earnings can be provided. A photocopy of this authorisation will be considered as effective and valid as the original. Signature Date: / / Signature Date: / / Section H Refund of Excess following Collision or Theft Please ensure a copy of your hire agreement, damage report and any invoicing is attached. The following documents are required in support of your claim (Please tick ( Hire Agreement Damage Reports Invoices ) when attached); Date damage occurred: / / Please state exactly what happened (with a sketch if applicable/helpful); SAHF Page 4 SIA CTI-CF 0609

5 Medical Certificate Completion by Doctor The Claimant must obtain at their own expense from the patient s usual doctor in all cases of cancellation and medical claims resulting from accident, illness or death. Important: The medical attendant is respectfully required to give as much detail as possible in order to assist our client and avoid the necessity of additional enquiries. 1. Name the person to whom this certificate applies (ie the person whose injury, illness or death occurred). 2. (a) (b) 3. (a) (b) Age Date of Birth Are you his/her usual medical attendant? If so, for how long? 4. Please give precise details of the nature of the accident, illness or injury. 5. State date of onset of illness, or date injuries were received. 6. State date on which you were first consulted in relation to the condition described in Question 4 and, in your opinion, how long the condition has been present prior to consultation. 7. Are you prepared to certify that solely due to the condition described in Question 4 the claimant(s) was/were compelled to cancel the travel arrangements? 8. What treatment, if any, has your patient previously received for this or any other related condition and when was treatment received? 9. Is he/she suffering from any chronic disease or illness or from any physical defect or infirmity? 10. If the claim is as a result of a death in your opinion was it sudden and unexpected? Please give reasons for your answer. Date I certify that the foregoing statements are correct. Doctor Signature Telephone Print Name: Address SAHF Page 5 SIA CTI-CF 0609

6 Dispute Resolution We and Savannah will do everything possible to provide a quality service to You. However, We recognise that occasionally there may be an aspect of Our or Savannah s service or a decision We or Savannah have made that You wish to query or draw to Our or Savannah s attention. Savannah has complaints and dispute resolution procedures which undertakes to answer Your complaints within 15 working days. If You have any concerns or complaints, please contact Savannah, Savannah s staff are always available to listen to You and to help where they can. If You would like to make a complaint or access Savannah s internal dispute resolution service, please contact Savannah and ask to speak to Savannah s dispute resolution specialist. See Savannah s contact details below. If You are not happy with Savannah s answer or Savannah has taken more than 15 working days to respond You many take Your complaint to the Financial Ombudsman Service (FOS) as ASIC approved external dispute body. The FOS resolves certain insurance disputes between consumers and insurers and will provide an independent review at no cost to You. We and Savannah are bound by any determination made by the FOS but the determination is not binding on You. The contact details of the FOS are as follows: Financial Ombudsman Service Limited (FOS) GPO Box 3 MELBOURNE VIC 3001 Freecall: Fax: (03) Web: Declarations and Authority: Privacy The Privacy Act 1988 requires us to tell you that on behalf of the Insurer we collect your personal information and sensitive information in order to calculate your loss and entitlement, determine our liability, compile data and handle claims. When handling claims we may have to disclose and obtain your personal and other information to and from third parties such as other insurers, reinsurers, loss adjusters, medical attendants, external claims data collectors, investigators and agents, to the Insurance Reference Services (IRS) or other parties as required by law. You have the right to seek access to your personal information and to correct it at any time. Please contact Savannah Insurance Agency Pty Ltd and advise us of the changes. Declaration: Claimant (Traveller) I/We certify that the information given in this form is truthful, accurate and complete. No information likely to affect this claim has been withheld. I/We understand that this claim may be refused if information is untrue, inaccurate or concealed. I/We acknowledge that I/We have read and understood the Privacy Act 1998 information and Medical Authority referred to above and consent to the collection, storage and use and disclosure of my/our personal sensitive information. I/We acknowledge that if I/We do not agree to the collection of this personal and sensitive information then Savannah Insurance Agency Pty Ltd will be unable to process my/our claim. Signature: Claimant (Traveller) Date: Print Name: Declaration: Parent/Legal Guardian (if applicable) I/We certify that the information given in this form is truthful, accurate and complete. No information likely to affect this claim has been withheld. I/We understand that this claim may be refused if information is untrue, inaccurate or concealed. I/We acknowledge that I/We have read and understood the Privacy Act 1998 information and Medical Authority referred to above and consent to the collection, storage and use and disclosure of my/our personal sensitive information. I/We acknowledge that if I/We do not agree to the collection of this personal and sensitive information then Savannah will be unable to process my/our claim. Please circle- Parent / Legal Guardian s Signature: Date: Print Name: Please note we are unable to process any claim without a signed declaration. Savannah Insurance Agency Pty Ltd GPO Box 4920 SYDNEY NSW 2001 Tel: (02) Fax: (02) SAHF Page 6 SIA CTI-CF 0609

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