SINGLE/MULTITRIP TRAVEL

Transcription

1 SINGLE/MULTITRIP TRAVEL CLAIM FORM FOR MEDICAL EXPENSES AND TRIP INTERRUPTION Once completed, please return your claim to: FAX: Mail address: 2250 NW 136 Av. Suite 100 Pembroke Pines, FL Thank You for notifying us of your claim. Please complete this claims form and return it to AMERICAN ASSIST as soon as possible. Please write clearly and in BLOCK CAPITALS. Please provide full supporting documentation to avoid delays in processing your claim. Claim Details (The Insured Claimant (s)): Title Full Name (s) Date Of Birth Occupation Claimant Address: Zip code: Telephone: Fax: Country of Residence: Certificate Number (Including Prefix): 1

2 Travel Destination: Country: City: Hotel: Departure Date: / / Return Date: / / Purpose of trip: Business / Pleasure If Business Please Provide Details of nature of work: If your Claim is agreed, how would you like to be paid? Please choose preferred method of payment: Check: (US bank accounts only) Confirm Payee name: Direct to your Bank account Bank Name: Swift: ABA No.: Account No.: Account Holder: By money transfer e.g Western Union: Place of pick up: Beneficiary: 2

3 DOCUMENTS REQUIERED TO SUPPORT CLAIMS: PLEASE PROVIDE: 1. All the receipts for expenses incurred and booking invoice. 2. Additional travel tickets. 3. Medical Record done by the medical center or Hospital, including the diagnosis. 4. If hospitalized, written confirmation from the hospital including date/time admitted and discharge, the triage notes from the hospital and the detailed bill. 5. If an early return was necessary, Letter from the treating Doctor abroad confirming the medical necessity to return to the country of residence earlier than planned, including the diagnosis and the reason to return. 6. For Medical Expenses, please complete the attached disclaimer in full. Medical Expenses and Trip Interruption Date, time and place of illness/injury: / / : AM/PM Illness suffered or injuries sustained: Details of any previous history: If injury, state circumstances: Did you contact the emergency services as on the policy: YES/NO Period of extended accommodation (if applicable) from / / to / / What were your original travel arrangements: If hospitalized: Date/time admitted / / : AM/PM Date/time discharge / / : AM/PM Were any additional expenses incurred in returning home? YES/NO (if yes, enter reasons and costs) 3

4 In case of early return through illness or injury please complete the following: Date on which you returned: / / Were you accompanied? YES/NO If YES, by whom: Reason for the trip interruption: Were any additional expenses incurred? YES/NO PLEASE REMEMMBER TO ENCLOSE WRITTEN CONFIRMATION FROM THE DOCTOR ABROAD THAT IT WAS MEDICALLY NECESSARY FOR YOUR TRIP INTERRUPTION. Please list expenses being claimed and treatment received Currency paid and amount claimed Receipt attached State to whom payment should be made 4

5 DECLARATION this must be signed. I/We declare that the above statements are true and correct to the best of my/our knowledge and belief. I/We have not withheld any information within my/our knowledge connected with this claim. I/We agree to provide the insurer with any further information as may be reasonably required. I/We understand that the insurer does not admit liability by issue of this form. WARNING the making of a fraudulent or knowingly exaggerated claim is a criminal offence. We investigate all cases and any person suspected of fraud is reported to the police with whom we always co-operate. DATA PROTECTION ACT The insurance industry operates a number of anti-fraud initiatives. The information given on this form may be stored electronically and may be shared with other organizations for this purpose. I/We understand that you may ask for information from other organizations to check the answers I/We have provided. Signature(s): Date: / / DISCLAIMER I hereby consent the insurance company seeking reimbursement of Medical Expenses paid by them arising out of medical treatment: Received in (destination): Signed: From: (date of accident/illness): / / Dated: / / Print Name: Full residence address: Date of Birth: / / Nationality: Full Name of Child (if applicable): Date of Birth of Child (if applicable): Nationality of child (if applicable): Date of Departure Abroad: / / 5