Trip Cancellation / Trip Interruption Claim Form

Transcription

1 Trip Cancellation / Trip Interruption Claim Form To report a claim, return the required documentation detailed below, along with your original, signed claim form to itravelinsured, Inc. (iti ). A delay in the processing of the claim may occur if the claim form is not completed. Proof of claim must be submitted within 90 days of the date of loss unless your state mandates otherwise. It is a crime as defined by applicable state law for any person to provide false or misleading information to an insurer for the purpose or intent of defrauding the insurer. Applicable law may include penalties for imprisonment and/or fines, as well as allowing the insurer to deny benefits and/or rescind any coverage. Required Documentation CANCELLATION TERMS AND CONDITIONS Brochure: Refund: Airline Tickets: Hotel or Cruise Vouchers: The Tour Operator, Cruise Line or other travel supplier s printed version of cancellation terms and conditions. It explains, in writing, what happens if you have to cancel your trip. A copy of any document that shows any amount refunded to you for this trip from anyone other than itravelinsured. We require the actual airline tickets if they are non-refundable. If you were issued e-tickets, we need the e-ticket passenger receipt. If you booked the flight over the Internet, we need the printed ticket confirmation sheet with your ticket numbers. We require any voucher(s) you receive that are non-refundable through any source. PROOF OF PAYMENT FOR TRIP AND/OR ADDITIONAL EXPENSES Receipts: Credit card statements, cancelled check or cash receipts for every payment made on the trip must be submitted with the claim. If this documentation is not available, contact the travel agent for an invoice that shows the date(s) and amount(s) of all payments made. Trip Invoice: A copy of the trip invoice that reflects the breakdown of the total trip costs (e.g. airfare, cruise/land costs, taxes, etc.). PROOF OF REASON FOR THE CLAIM Doctor s Statement: Medical Authorization: Death Certificate: Cancelled for Nonmedical Reasons The doctor s statement (i.e. the Certificate of Medical History, Part 5, of this form) must include the specific diagnosis, date of treatment and date of advisement of cancellation. The Patient Consent to Disclose Health Insurance form (Part 6) is included in this form. We require the sick/injured party s signature in order to allow us to contact the doctor if we need additional information to process the claim. A delay in the processing of the claim could occur if this is not provided. If the cancellation is due to a death, a copy of the death certificate is needed. In some instances, proof of relationship to the deceased may be needed (e.g. birth certificate, marriage license, etc.). Submit supporting documentation for the reason the trip was cancelled/interrupted (e.g. death certificate, employment letter due to termination including dates of employment, travel supplier documentation to support cancellation, etc.). INSURED INFORMATION Insured s Name (Last, First, Middle): Group Travel Insurance Complete Home Work Form iti-45 Trip Cancellation / Trip Interruption Claim Form Page 1 of itravelinsured, Inc. All rights reserved.

2 PART 1. GENERAL INFORMATION 1. Full Name of Person(s) Claiming: (If additional travelers, please attach a separate sheet) 2. Full Name of Person Claiming: 3. Full Name of Person Claiming: 4. Full Name of Person Claiming: Name of Travel Supplier (e.g. Cruise Line, Airline, etc.): Travel Agency s Full Name: Travel Agency s Complete Travel Agent s Name: Initial Deposit Date Paid for Trip Final Payment Date Departure Date Schedule Return Date Actual Return Date Departure City: Destination (City, Country or State): Please click the applicable box: q Trip Cancellation q Trip Interruption ff If the cancellation and/or interruption is due to a medical reason(s), please complete the entire claim form. ff If the cancellation and/or interruption is due to a non-medical reason(s), please complete Parts 2 and 4. PART 2. EXPLANATION OF LOSS Reason for Cancellation/Interruption: Date Trip Cancelled/Interrupted Total Amount of Trip, Not Including Cost of Travel Insurance (US$): Trip Cost per Person (US$): Cost of Airfare per Person (US$): Did you or will you receive a refund from the Travel Agent/Travel Supplier? q Yes q No If Yes, please indicate the amount refunded (US$): Please list any additional expenses incurred due to the Trip Interruption (e.g. accommodations, meals): Type of Expense: Date Incurred Amount (US$): Please use a separate sheet of paper for any additional expenses. Enclose receipts for the above expenses. The claim cannot complete processing without the receipts. _ Form iti-45 Trip Cancellation / Trip Interruption Claim Form Page 2 of itravelinsured, Inc. All rights reserved.

3 PART 3. MEDICAL INFORMATION Patient s Name: Nature of Illness: Describe onset, diagnosis and treatment: Relationship to Insured: Date Symptoms First Noticed Date of First Consultation For Injury, describe Injury: How and where did the accident occur: Date of First Consultation If hospitalized, hospital name and address: Name and Address of Treating Physician: PART 4. OTHER COVERAGE Dates of Confinement From: To: Do you have any other insurance coverage / medical plans (e.g. medical, travel, etc.)? q Yes q No Do you have any travel other insurance coverage with credit card holders (e.g. evacuation, assistance, travel delay, baggage loss, etc.)? q Yes q No Did you report the loss to any other insurance company? q Yes q No If Yes, which company: Name of Company: Policy/ (Please attach a separate sheet if necessary) AUTHORIZATION I declare that the above information is true, complete and correct. I/We authorize any other insurance plan, under which I/We have coverage, to disclose information as may be necessary or to make payment in respect of my/our claim to iti directly. I/We also authorize to iti, to disclose to any other Plan, under which I/We have coverage, any and all information as may be necessary with respect to my/our claim. Date Date Date Date Form iti-45 Trip Cancellation / Trip Interruption Claim Form Page 3 of itravelinsured, Inc. All rights reserved.

4 PART 5. CERTIFICATE OF MEDICAL HISTORY. TO BE COMPLETED BY INSURED. Patient s Name: Insured s Name: Date Relationship to Patient: Certificate Purchase Date ATTENDING PHYSICIAN S STATEMENT. MUST BE COMPLETED BY THE PHYSICIAN. 1. Diagnosis: Nature of Illness/Injury causing Cancellation/Interruption (Please be specific): a. Primary Diagnosis b. Secondary Diagnosis 2. When did symptoms first appear or injury occur (Mo., Day, Yr.)? 3. When did the patient first consult you (Mo., Day, Yr.)? 4. If patient was referred from another physician, name of physician, address and telephone number 5. Name, address, and telephone number of other physicians involved: 6. If condition causing Cancellation/Interruption is of a long-standing nature, was the patient medically fit to travel on the Policy Purchase Date indicated above? q Yes q No If No, please explain: 7. Dates of all medical visits, as it relates to the condition causing Cancellation/Interruption: Date of Consultation Describe the Condition/Treatment: Medication(s) Prescribed/Changed: (Please attach a separate sheet if necessary) 8. Has the patient been hospitalized for this condition or related condition(s) in the past 60 days? q Yes q No If Yes, date of admittance Date of discharge 9. From what date did this condition prevent the patient from traveling (Mo., Day, Yr.)? 10. If the patient is not the insured, from what date was travel precluded for the insured due to the patient s condition (Mo., Day, Yr.)? 11. On what date was this condition stable and controlled to permit travel (Mo., Day, Yr.)? 12. Did you advise the patient/insured to cancel travel plans prior to departure or return home early a result of this medical condition? q Yes q No If Yes, on what date (Mo., Day, Yr.)? Please explain: If No, on what date was it reasonable for the patient/insured to cancel/interrupt their travel plans (Mo., Day, Yr.)? 13. If condition was related to pregnancy, date of last menstrual cycle? Expected Delivery Date? 14. Was this Illness/Injury the sole cause of the patient s disability leading to cancellation/interruption? q Yes q No If No, please explain: Physician s Remarks: Signature of Physician: Name of Physician: Date Completed Address of Physician: Taxpayer ID Number: Form iti-45 Trip Cancellation / Trip Interruption Claim Form Page 4 of itravelinsured, Inc. All rights reserved.

5 PART 6. PATIENT CONSENT TO DISCLOSE HEALTH INFORMATION Patient s Full Name at Time of Treatment: Purpose of Release: ADJUDICATION OF TRAVEL INSURANCE CLAIM Effective Date of Travel Insurance Coverage Medical Facilities - List all doctors consulted for this condition and hospitals where confined: 1. Name: 2. Name: 3. Name: You are authorized to give iti or any agent or administrator acting on its behalf any information concerning coverage, medical care, advice, treatment or supplies, the financial or employment status of the insured named below, or any other information that may have bearing on the request for benefits submitted in conjunction with the Group Travel Insurance Certificate. Information to be released: All medical records of the Patient from sixty (60 days) before the Effective Date of Group Travel Insurance Coverage as shown above through the date of this consent as shown below. Medical records includes, without limitation, diagnosis list, medication list, physician dictation, office notes, physical therapy records, occupational therapy records, pathology reports, cytology reports and the results of all laboratory tests. Send to: itravelinsured P.O. Box Indianapolis, IN Telephone: Fax: By signing below, I understand that: 1. The information in my health record may include information relating to behavioral or mental health services, and treatment for alcohol and drug abuse. 2. I have the right to revoke this consent at any time by providing my written revocation to the facility where my records are kept. 3. A revocation will not apply to information that has already been released in response to this consent. 4. A revocation will not apply to my insurance company where the law provides my insurer the right to contest a claim under my certificate. 5. Unless otherwise revoked, this consent will expire in twelve (12) months. 6. Consenting to the disclosure is voluntary. I can refuse to sign the consent, but doing so will delay my claim. Signature of patient or authorized person: Date Relationship/reason patient is unable to sign: itravelinsured, Inc. P.O. Box Indianapolis, IN Telephone: or Fax: Form iti-45 Trip Cancellation / Trip Interruption Claim Form Page 5 of itravelinsured, Inc. All rights reserved.