Important notice each incident requires a separate claim form. Postal Address Risk/Cost Centre
|
|
- Jade Wilkins
- 8 years ago
- Views:
Transcription
1 Travel Claim Form 221 St George s Terrace, Perth GPO Box K837 Perth WA 6842 Telephone (08) Facsimile (08) Website Important notice each incident requires a separate claim form THE FOLLOWING GUIDE IS TO ASSIST YOU IN COMPLETING THIS CLAIM FORM Type of Claim Sections to complete Personal Accident/Medical Expenses 1, 2, 3, 4 and 10 Baggage 1, 2, 3, 5 and 10 Additional Expenses 1,2, 3, 6 and 10 Money/Documents 1,2, 3, 7 and 10 Loss of Deposit/Cancellation 1, 2, 3, 8 and 10 Personal Liability 1, 2, 3, 9 and AGENCY DETAILS Agency Name Postal Address Risk/Cost Centre Phone Fax 2. CLAIMANT AND GENERAL DETAILS Family Name Given Name Date of Birth / / Phone Address Suburb/Town 1. Person s relationship to the Agency (e.g. Employee, etc) 2. Did the claim occur during an authorised business trip for the Agency? Yes No If No, give details 3. Advise details of journey: Departure Date / / From: To: Return Date / / 4. Date of incident / / Time am/pm 5. When was the incident discovered? (if appropriate) / / 6. Where did the incident occur? 7. Describe the nature of the claim: Form 469/7/07 Page 1
2 8. Is there any other insurance covering any part of the claim? Yes No If Yes, advise nature of policy, name of Insurance Company and Policy No. 9. Have you claimed for any benefit or refund or are you entitled to claim from any source whatsoever (including any private health insurance fund, insurance company, Medicare or Workers Compensation Act) in respect of this incident (including medical expenses)? Yes No If Yes, advise details and amounts of such benefits or refunds 3. WITNESS DETAILS (if applicable) Name Address Daytime Contact Number 4. PERSONAL ACCIDENT/MEDICAL EXPENSES Note: Medical, Additional out of pocket Expenses and Loss of Deposits claims first obtain the refunds from Medicare and/or Private Health Fund (if any), then enclose all relevant medical certificates or death certificate, accounts, receipts, documents and statement of benefit from Medicare and/or Private Health Fund to support the claim. 10. How long has the person been confined to: Bed: From / / to / / House: From / / to / / Hospital: From / / to / / 11. Advise name and address of doctor(s) attending the person 12. If admitted to Hospital, advise name of the Hospital 13. Are you a member of a private health insurance fund? Yes No If Yes, advise the name of Fund and the policy number 14. Advise the name and address of your usual Medical Practitioner: 15. Advise details of amounts claimed: NET AMOUNT CLAIMED Form 469/7/07 Page 2
3 5. BAGGAGE Note: Attach invoices, valuations or receipts to support the value of the items being claimed and acknowledgement or documents issued by the Police, Hotel, Carrier or other Authority supporting the notification of the loss. 16. Was the property lost or damaged wholly owned by you? Yes No If No, advise details of ownership 17. Was the loss or damage reported to the police, airline, carrier, hotel or other authority? Yes No If Yes, advise to whom and date reported 18. Has any of the property been recovered or has any arrest been made? Yes No If Yes, give details 19. (a) If you consider any party or person(s) responsible for the loss or damage, provide their name(s) and address(es). (b) Have you lodged a claim or complaint against the responsible party? Yes No If Yes, give details and attach copies of correspondence. 20. Have any arrangements been made for replacement of or repairs to the property? Yes No If Yes, give details 21. Schedule of property lost or damaged Items Lost or Damaged Quantity Date of Purchase Total Replacement Cost Price Value of Salvage (if any) RiskCover Use Only Depreciation where applicable Amount payable A$ Total Amount Payable Form 469/7/07 Page 3
4 6. ADDITIONAL ACCOMMODATION AND/OR TRAVEL EXPENSES 22. Advise details of additional expenses incurred by you: NET AMOUNT CLAIMED 7. MONEY/DOCUMENTS Note: Attach acknowledgement or documents issued by the Police, Hotel, Carrier or other Authority supporting the notification of the loss. 23. Was the money/documentation which was lost or damaged wholly owned by you (e.g. credit card, cheques, travel documents etc)? Yes No If No, advise details of ownership 24. Was the loss reported to the police, airline, carrier, hotel or other authority? Yes No If Yes, advise to whom and date reported 25. Has any of the property been recovered or has any arrest been made? Yes No If Yes, give details 26. Advise details of the loss or damage and amount of claim: AMOUNT CLAIMED Form 469/7/07 Page 4
5 8. LOSS OF DEPOSIT/CANCELLATION Note: Written confirmation of the amount lost must be obtained from the travel agent, transportation company and/or accommodation provider. 27. What date did you advise the travel agent, transport and/or accommodation provider? / / Please advise the company name, address, contact name and telephone number 28. Were any alternative arrangements offered or made? Yes No If Yes, advise details 29. Have you applied for a refund of fares or bookings made? Yes No If Yes, advise amount of refund If No, advise reason 30. Advise details of claim: Amount of deposit paid and date paid / / Balance of costs and date paid / / PAID Less refund received on cancellation NET AMOUNT CLAIMED 9. PERSONAL LIABILITY Note: Attach all letters or claim demands made against you. No admission of liability, either implied or expressed, should be made. Any claim made upon you should simply be acknowledged with advice that the matter has been referred to RiskCover for determination. 31. Provide details of the person making the claim against you including name, address and daytime contact number: 10. DECLARATION I declare that the details submitted are true and correct and that I am the person authorised to lodge the claim against RiskCover on behalf of the above-mentioned Agency. Signature of person having authority Name Phone Title Date / / Form 469/7/07 Page 5
Corporate Travel and Personal Accident Insurance Claim Form
Claim : Corporate Travel and Personal Accident Insurance Claim Form Prepared 03 January 2012 Email: travelclaims@allianzassistance.com.au Phone: 1800 761 173 Facsimile: (07) 3360 7854 Postal Address: Claims
More informationName of Traveller Mr Mrs Miss Ms. Occupation: Date of Birth / /
Travel Insurance Report Form Claim Report This issue of this form is not an admission of liability and is without prejudice. All questions in this section must be answered Name of Traveller Mr Mrs Miss
More informationTravel Insurance Report Form
ACE Insurance Limited ABN 23 001 642 020 28-34 O Connell Street Sydney NSW 2000 Australia GPO Box 4065 Sydney NSW 2001 Australia (02) 9335 3355 main (02) 9231 3697 fax www.aceinsurance.com.au 1800 815
More informationTravel Insurance Claim Form
Travel Insurance Claim Form 1 TRAVELLER details Please print your details clearly in CAPITAL letters using a pen Policy Number Name of Traveller (Mr/Mrs/Ms/Miss) Name of Policy Owner Telephone Home/work
More informationTravel Insurance Report Form
ACE Insurance Limited ABN 23 001 642 020 28-34 O Connell Street Sydney NSW 2000 Australia GPO Box 4065 Sydney NSW 2001 Australia (02) 9335 3355 main (02) 9231 3697 fax www.aceinsurance.com.au 1800 815
More informationTravel Insurance Report Form
ACE Insurance Limited ABN 23 001 642 020 28-34 O Connell Street Sydney NSW 2000 Australia GPO Box 4065 Sydney NSW 2001 Australia 1800 688 640 claims phone 1800 815 675 customer service +61 (0)2 9231 3697
More informationCitibank Travel Insurance Claim Form
ACE Insurance Limited ABN 23 001 642 020 AFSL. 239687 Level 1, 51 Berry Street rth Sydney NSW 2060 Australia PO Box 403 rth Sydney NSW 2059 Australia 1800 305 422 (02) 8912 9704 (02) 9231 3697 +61 2 8912
More informationEmail. Name of Intermediary (if any) Gender Male Female Age Date of Birth D D / M M / Y Y Y Y. Date of Employment D D / M M / Y Y Y Y.
TRAVEL INSURANCE Claim Form *SG021* *SG021* TO FACILITATE THE PROCESSING OF YOUR CLAIM, YOU ARE REQUIRED TO COMPLETE SECTIONS A, B AND C FOR ALL CLAIM SUBMISSIONS. The issue and acceptance of this form
More informationExpiry Date. If you have selected Cheque please nominate payee
TRAVEL INSURANCE CLAIM FORM IMPORTANT: PLEASE READ BEFORE YOU COMPLETE THIS FORM 1. Please answer all questions and provide all relevant documentation to avoid delays with your We are unable to process
More informationTravel Insurance Claim Form
Travel Insurance Claim Form for BNZ Credit Cards 1 TRAVELLER details Please print your details clearly in CAPITAL letters using a pen Traveller (MrMrsMsMiss) Telephone Homework ( ) Mobile ( ) Email Address
More informationIMPORTANT INFORMATION
ACE JERNEH INSURANCE BERHAD (formerly known as Jerneh Insurance Berhad) (9827-A) Claim Services Department, Level 26 Menara Weld, 76 Jalan Raja Chulan, 50200 Kuala Lumpur, Malaysia 1800 88 2846 Tel 03
More informationSingapore Airlines Claim Form
Singapore Airlines Claim Form IMPORTANT NOTE: Please answer all questions contained in this claim form as leaving items blank, using ticks, dashes and N/A may make it necessary for us to return your claim
More informationClaim Form TRAVEL INSURANCE
ACCIDENT & HEALTH INTERNATIONAL Claim Form TRAVEL INSURANCE Sydney Level 4, 33 York Street Sydney NSW 2000 GPO Box 4213, Sydney, NSW, 2001 T: +61 2 9251 8700 F: +61 2 9252 4385 ABN: 26 053 335 952 AFS
More informationTRAVEL INSURANCE CLAIM FORM
PLEASE READ BEFORE COMPLETING FORM 1. THIS FORM MUST BE FULLY COMPLETED IN THE SECTIONS APPLICABLE TO YOUR CLAIM. 2. THE PRIVACY CONSENT SECTION MUST BE SIGNED. 3. The issue of this form is not an admission
More informationClaim Form Travel Insurance
United Overseas Insurance Limited 3 Anson Road #28-01 Springleaf Tower Singapore 079909 Tel: (65) 6222 7733 Fax: (65) 6327 3869 / 6327 3870 Email: ContactUs@uoi.com.sg uoi.com.sg Co. Reg. No. 197100152R
More informationFEDERAL INSURANCE COMPANY One of the Chubb Group of Insurance Companies
FEDERAL INSURANCE COMPANY One of the Chubb Group of Insurance Companies 18 Cross Street #11-08 China Square Central Singapore 048423 Telephone: 6333 8113 Facsimile: 6333 8112 Unique Entity No. S83FC3361G
More informationTravel Claims Form STEP 1 CLAIM FORM COMPLETION REQUIREMENTS STEP 2 CLAIMANT DETAILS. Policy and Claimant Details. A. Travel Arrangements
STEP 1 CLAIM FORM COMPLETION REQUIREMENTS Please read and complete this form. Please retain a copy of ALL documents for your records. Documents in a foreign language are required to be translated into
More informationAVANT TRAVEL INSURANCE CLAIM FORM
AVANT TRAVEL INSURANCE CLAIM FORM IMPORTANT: PLEASE READ BEFORE YOU COMPLETE THIS FORM 1. Pleas e answer all questions and provide all relevant doc umentation to avoid delays with your claim. We are unable
More informationName of Traveller Mr Mrs Miss Ms. For prompt settlement please attach original or photostat copy of Insurance Certificate
The provision of this form by AIG is not an admission of liability or acceptance by AIG of your claim. All questions in this section must be answered Name of Traveller Mr Mrs Miss Ms Occupation: Date of
More informationName of Traveller Mr Mrs Miss Ms. For prompt settlement please attach original or photostat copy of Insurance Certificate
Staff/Student ID No. The provision of this form by AIG is not an admission of liability or acceptance by AIG of your claim. Please keep a photocopy of all documentation you send to us for your own records.
More informationTRAVEL INSURANCE CLAIM FORM
TRAVEL INSURANCE CLAIM FORM Claims Enquiries call: +(60) 3 6207 4115 or 1 800 806 377 (within Malaysia) E-Mail: MHinsure-claims@mondial-assistance.com.my Mail: MHinsure Claims Level 14, Tower B, Dataran
More informationOverseas Travel Insurance claim form
Overseas Travel Insurance claim form for ANZ Visa Gold, ANZ Gold MasterCard and Qantas ANZ Visa Platinum cards By following the simple steps listed below you can avoid unnecessary delays when your claim
More informationCLAIM FORM - EQ TRAVEL. Section 1 - Particulars of Insured. Section 2 - Details of Incident/Loss/Illness (must be completed)
CLAIM FORM - EQ TRAVEL Agency: Policy No.: Please note: Sections 1, 2 and 12 must be completed. Sections 3 to 11 complete only the relevant sections. The acceptance of this form is NOT an admission of
More informationPlease print out for signatures and post original to your broker if applicable or to AIG Insurance New Zealand Limited.
Corporate Travel Insurance Claim Form Please print out for signatures and post original to your broker if applicable or to AIG Insurance New Zealand Limited. Corporate Policies Only: This section MUST
More informationTravel Insurance Claim Form
Jetstar Travel Travel Insurance Insurance Claim Form IMPORTANT NOTE: Please answer all questions contained in this claim form as leaving items blank, using ticks, dashes and N/A may make it necessary for
More informationCorporate Travel Claim Form
Corporate Travel Claim Form Important Notice The acceptance of this Form is NOT an admission of liability on the part of Zurich Insurance Company Ltd (Singapore Branch) (the Company ). Any documentary
More informationClaim Form Travel Insurance
United Overseas Insurance Limited 3 Anson Road #28-01 Springleaf Tower Singapore 079909 Tel: (65) 6222 7733 Fax: (65) 6327 3869 / 6327 3870 Email: Claims@uoi.com.sg uoi.com.sg Co. Reg. No. 197100152R Claim
More informationHow To Claim From Safari Safari Insurance In Korea
Date sent to us: / /20 Claim Reference Number (if known): Please answer all relevant questions on the claim form. Leaving items blank, using ticks, dashes and n/a may result in us returning the claim form
More informationFEDERAL INSURANCE COMPANY One of the Chubb Group of Insurance Companies
FEDERAL INSURANCE COMPANY One of the Chubb Group of Insurance Companies 18 Cross Street #11-08 China Square Central Singapore 048423 Telephone: 6333 8113 Facsimile: 6333 8112 Unique Entity No. S83FC3361G
More informationFor all claims the following documents must be sent to us along with this claim form:
IMPORTANT: please read this before you start Use the check list below to help you complete your claims form, and identify documents you will need to attach. We don t want you to miss something. Delays
More informationtravel insurance travel claim report
claim report travel insurance travel CGU Insurance Limited ABN 27 004 478 371 An IAG Company Please retain this page for your information IMPORTANT Please read this before completing the report. Please
More informationFEDERAL INSURANCE COMPANY One of the Chubb Group of Insurance Companies
FEDERAL INSURANCE COMPANY One of the Chubb Group of Insurance Companies 18 Cross Street #11-08 China Square Central Singapore 048423 Telephone: 6333 8113 Facsimile: 6333 8112 Unique Entity No. S83FC3361G
More informationChubb Worldwide Travel
Chubb Worldwide Travel Claim Form Important Information Prior to submitting your claim please complete the relevant sections of this Claim Form. Policy and Claimant Details and Payment Details must be
More informationTravelCare Claim Form
TravelCare Claim Form To help us process your claim quickly, please follow these guidelines: 1. Complete a separate claim form for each claim and for each insured person. 2. If you are submitting a claim
More informationTravel Claim Form. E mail Address: I.D. Card No. Age. Occupation Name of Employer. Telephone No. Home: Mobile: Business:
Return this form together with all necessary documents to: GasanMamo Insurance, Msida Road, Gzira GZR 1405 Malta For any queries please call 21 345 123 ext 5 Travel Claim Form Branch/Broker/TII Claim Number
More informationMaking a claim with Suresave
Making a claim with Suresave Before you start In order for us to process your claim quickly it s important that you complete all the relevant sections of this form with as much detail as you can If you
More information2. For cancellation or amendment of travel arrangements due to you or your relatives illness /death (Complete Sections A, C D and E)
IMPORTANT: please read this before you start Use the check list below to help you complete your claims form, and identify you will need to attach. We don t want you to miss something. Delays can occur
More information...making travel insurance easy
Dear Sir/Madam, We understand that you need to make a claim on your travel insurance policy. To ensure we can assess and finalise your claim as quickly as possible and to avoid unnecessary delays, please
More informationQBE travel insurance claim form
QBE travel insurance claim form QBE Insurance (Australia) Limited ABN 78 003 191 035 AFSL 239 545 Office use only Claim number Please answer all questions and tick boxes where appropriate Leaving a question
More informationWe are writing further to your request for a claim form and are very sorry to note the circumstances described.
InsureandGo Claims PO Box 5775 Southend-on-Sea Essex SS1 2JY Dear Sir / Madam, TRAVEL INSURANCE CLAIM We are writing further to your request for a claim form and are very sorry to note the circumstances
More informationClaim Number. Departure Date: From / / To / / Occupation Date of Birth / / Date of Booking Travel Arrangements Date of Departure Date of Return
Savannah Insurance Agency Pty Ltd ABN 84 130 364 313 Corporate Travel Claim Form Details of the Insured Insured Name (Traveller) Policy Number Claim Number IMPORTANT 1. Please complete the Policy Details
More informationTRAVEL INSURANCE - Claim Procedure
TRAVEL INSURANCE - Claim Procedure Claim Procedure: 1) Claim Intimation to Insurance Company through us or Directly on toll free no. 2) Submission of Claim form and Required Documents. Claim payable for:
More informationINSURANCE CLAIM FORM
INSURANCE CLAIM FORM This purpose of this document is to help you complete your insurance claim. Please read the instructions below and carefully follow them, this will enable us to complete the assessment
More informationWe are writing further to your request for a claim form and are very sorry to note the circumstances described.
PO Box 5775 Southend-on-Sea Essex SS1 2JY Dear Sir/Madam Travel Insurance Claim We are writing further to your request for a claim form and are very sorry to note the circumstances described. In order
More informationCLAIM FOR COMPENSATION FOR A WORK-RELATED DEATH
CLAIM FOR COMPENSATION FOR A WORK-RELATED DEATH Seafarers Rehabilitation and Compensation Act 1992 Information about claiming compensation In this document, all references to the employer mean the employer
More informationTravel Insurance Claim Form
CLAIMAINTS DETAILS Policy Number Departure Date Return Date Title First Name Surname ID / Passport Number Email Address Mobile Number Business Contact No Home Contact No Fax No Postal Address Postal Code
More informationMaking a claim with COTA
Making a claim with COTA Before you start In order for us to process your claim quickly it s important that you complete all the relevant sections of this form with as much detail as you can If you do
More informationAPPLICANT'S DETAILS: Please write using BLOCK LETTERS in DARK INK
(28 Febuary 2008) Please write using BLOCK LETTERS in DARK INK 1 CRIMINAL INJURIES COMPENSATION Level 12, International House, 26 St George's Terrace, Perth WA 6000 Postal Address: GPO Box F317, PERTH
More informationJetProtect Domestic Travel Claim Form
JetProtect Domestic Travel Claim Form Claimant s Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Claimant s Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
More informationEasy Domestic Travel Insurance
Issuance of this form does not amount to admission of any liability or a waiver of any of the terms and conditions of the Policy. If any claim is in any manner dishonest or fraudulent, or is supported
More informationSPORTING ACCIDENT CLAIM FORM Please read this page first before completing the Claim Form
SPORTING ACCIDENT CLAIM FORM Please read this page first before completing the Claim Form Dear Member, Thank you for your Claim Form request. This letter contains important information relevant to your
More informationHOW TO GET EFFICIENT CLAIMS HANDLING:
HOW TO GET EFFICIENT CLAIMS HANDLING: For all claims, please provide the following: n Policy number (te, you do not need to provide this if you have insurance through your credit card) n If you have insurance
More informationTravel and Cancellation Policy Claim Form
Travel and Cancellation Policy Claim Form If any expenses that you are claiming are also insured elsewhere, you should submit your claim to that company first (e.g. under a medical, bicycle, caravan, annual
More informationThe issuance and acceptance of this form does NOT constitute an admission of liability by ACE Insurance Limited (ACE) or waiver of its rights.
HOME INSURANCE Claim Form *SG011* *SG011* IMPORTANT INFORMATION The information requested and documents mentioned in this form are a general guide. Further documents or information may be required depending
More informationIn the event of a claim, contact our 24-hour helpline numbers
CLAIMS FORM FOR GROUP TRAVEL INSURANCE Claimant s Name : Claimant s Address: Phone No.(Mobile): Phone No.(Res) : E-mail ID: Policy Start Date : dd/mm/yyyy Policy End Date : dd/mm/yyyy In what capacity
More informationTRAVEL INSURANCE CLAIM FORM
TRAVEL INSURANCE CLAIM FORM PT. CHINA TAIPING INSURANCE INDONESIA Wisma Argo Manunggal 19th Fl. Jl. Jend. Gatot Subroto Kav. 22 Jakarta 12930 THIS FORM IS ISSUED WITHOUT ADMISSION OF LIABILITY, AND IT
More informationMaking a claim with TID
Making a claim with TID Before you start In order for us to process your claim quickly it s important that you complete all the relevant sections of this form with as much detail as you can If you do not
More informationCLAIMS FORM FOR GROUP TRAVEL INSURANCE(DOMESTIC) Claimant s Name : Claimant s Address: Phone No.(Mobile): Phone No.
CLAIMS FORM FOR GROUP TRAVEL INSURANCE(DOMESTIC) Claimant s Name : Claimant s Address: Phone No.(Mobile): Phone No.(Res) : E-mail ID: Policy Start Date : dd/mm/yyyy Policy End Date : dd/mm/yyyy In what
More informationSmartTraveller Claim Form
AXA Affin General Insurance Berhad (23820-W) Ground Floor Wisma Boustead 71 Jalan Raja Chulan 50200 Kuala Lumpur (603) 2170 8282 (603) 2031 7282 customer.service@axa.com.my www.axa.com.my SmartTraveller
More informationSINGLE/MULTITRIP TRAVEL
SINGLE/MULTITRIP TRAVEL CLAIM FORM FOR MEDICAL EXPENSES AND TRIP INTERRUPTION Once completed, please return your claim to: claims@americanassist.com FAX: 1 305 749 0475 Mail address: 2250 NW 136 Av. Suite
More informationClaim for Compensation for a Work-related death
SRC 184 (March 2014) Claim for Compensation for a Work-related death This form is to be completed if you wish to claim compensation under the Safety, Rehabilitation and Compensation Act 1988 (SRC Act)
More informationPERSONAL ACCIDENT CLAIM FORM - MEMBERS
Pony Club Insurance Scheme PERSONAL ACCIDENT CLAIM FORM - MEMBERS Please read this page before completing the Claim Form Dear Member Thank you for your Claim Form request. This letter contains important
More informationNotification Claim Form
Notification Claim Form Claim Notification Reference: Your Details: Name: Type of Claim: Date: Address: (For Office Use Only) Contact Number: Email Address: Important information / What next? 1. Please
More informationTRAVEL CLAIM FORM TYPE OF CLAIM. Card No / Policy Receipt No Surname: First Names: Postal Address:
Chartis South Africa Limited P.O Box 31983 Braamfontein 2017 SA Share Call Tel: 0860 104 146 Tel: +2711 551 8533 Fax: +2711 551 8290 Email: SATravelClaims@chartisinsurance.com TRAVEL CLAIM FORM NOTES 1.
More informationTravel Guard Claims PO Box 60108 London, SW20 8US Tel: 0845 603 9892* Fax: 0870 130 1950
Travel Guard Claims PO Box 60108 London, SW20 8US Tel 0845 603 9892* Fax 0870 130 1950 Dear Sir / Madam, So that we may process your claim as quickly as possible please ensure that you fully complete and
More informationJetProtect Overseas Travel Claim Form
JetProtect Overseas Travel Claim Form Claimant s Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Claimant s Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
More informationInpatriate Medical Expenses Claim Form
ACE Insurance Limited ABN 23 001 642 020 28-34 O Connell Street Sydney NSW 2000 Australia GPO Box 4065 Sydney NSW 2001 Australia (02) 9335 3355 main (02) 9231 3697 fax www.aceinsurance.com.au 1800 027
More informationNTUC Income Travel Claim Submission Procedure
NTUC Income Travel Claim Submission Procedure Step 1 - Print the claim form. Step 2 - Complete the claim form and refer to the claim matrix for supporting documents required. Step 3 - Get the authorized
More informationPART D: PROSECUTION DETAILS
HOW TO COMPLETE YOUR CRIMINAL INJURIES COMPENSATION APPLICATION FORM PLEASE COMPLETE THE FORM USING DARK INK, AND ENSURE YOU KEEP A COPY OF YOUR APPLICATION FORM AND ALL YOUR DOCUMENTS. PART A: APPLICANT
More informationClaim for Compensation for a Work-related death
SRC184(Feb2008) Claim for Compensation for a Work-related death This form is to be completed if you wish to claim compensation under the Safety, Rehabilitation and Compensation Act 1988 (SRC Act) for the
More informationPersonal Injury Claim Form
ACE Insurance Limited ACE Insurance Limited GPO Box 4065 1800 688 640 claims phone ABN 23 001 642 020 ABN 23 001 642 020 Sydney NSW 2001 1800 815 675 customer service The ACE Building GPO Box 4065 Claims
More informationTitle Given name/s Surname Date of birth. Postal address Suburb State Postcode
NRMA Claim Form For assistance call: 1300 135 640 Submit your claim to NRMA Insurance by: Post: NRMA Insurance Claims, Claims Department Private Bag 913, North Sydney NSW 2059 Fax: (02) 9202 8098 Email:
More information...making travel insurance easy
Dear Sir/Madam, We understand that you need to make a claim on your travel insurance policy. To ensure we can assess and finalise your claim as quickly as possible and to avoid unnecessary delays, please
More informationJLT SPORT ASSET PROTECT CLAIM FORM
JLT SPORT ASSET PROTECT CLAIM FORM PLEASE USE BLOCK LETTERS WHILE COMPLETING THIS FORM CLAIMS HOTLINE: 1800 640 009 or call direct: (08) 8235 6455 Please forward your completed claim form to: Echelon Claims
More informationTitle Given name/s Surname Date of birth. Postal address Suburb State Postcode
AAA Auto Clubs Claim Form Submit your claim to Travel Insurance Partners by: Post: AAA Auto Clubs Claims Department PO Box 168, North Sydney NSW 2060 Fax: (02) 8362 9367 Email: claimsprocessing@travelinsurancepartners.com.au
More informationCONTENTS 1. PRIOR TO TRAVEL 2. PERSONAL ACCIDENT/TRAVEL INSURANCE 3. RESTRICTIONS TO TRAVEL FOREIGN OFFICE 4. INSURERS DETAILS AND POLICY NUMBER
CONTENTS 1. PRIOR TO TRAVEL 2. PERSONAL ACCIDENT/TRAVEL INSURANCE 3. RESTRICTIONS TO TRAVEL FOREIGN OFFICE 4. INSURERS DETAILS AND POLICY NUMBER 5. PERSONAL ACCIDENT 6. MEDICAL EXPENSES 7. CANCELLATION
More information2015 INSURANCE GUIDE ALUMNI PRIVATE TRAVEL INSURANCE
2015 INSURANCE GUIDE ALUMNI PRIVATE TRAVEL INSURANCE This guide is provided to University of Adelaide Alumni who wish to apply for cover under the University's Travel Insurance policy. The guide outlines
More informationCLAIM FOR WORKERS COMPENSATION
CLAIM FOR WORKERS COMPENSATION Seafarers Rehabilitation and Compensation Act 1992 Information about claiming workers compensation In this document, all references to the employer mean the employer against
More informationClaim Procedure Travel Insurance
Claim Procedure Travel Insurance In the event of loss, written notice of claim should be given to us within thirty (30) days after the occurrence, together with all relevant documents. A. Documents / information
More informationNotification Claim Form
Notification Claim Form Once completed, please return your claim form to: Intana Sussex House Perrymount Road Haywards Heath West Sussex RH16 1DN Thank you for notifying us of your claim. Please complete
More informationHERTZ Personal Accident & Effects Claim Form
HERTZ Personal Accident & Effects Claim Form Trust Name: ABN: (The issue of this form is not an admission of liability) JLT (Hertz PA/PE Cover) Discretionary Trust Arrangement This form should be completed
More informationMaterial Damage Contract Works
INSURANCE SOLUTIONS CLAIM FORM Material Damage Contract Works EXTF055 Call ATC Claims for assistance on 1800 994 694 1. This claim form must be completed by the named insured of the policy. 2. Check all
More informationTravel insurance claim form
NTUC Income Insurance Co-operative Limited NTUC Income Centre 75 Bras Basah Road Singapore 189557 Tel: 63 INCOME/6346 2663 Fax: 6338 1500 Email: csquery@income.com.sg Website: www.income.com.sg Travel
More informationYour People, Protected. Sports group Personal Accident Claim Form
Your People, Protected Sports group Personal Accident Claim Form Sports group Personal Accident/Claim Form 2 Claim Form Dear Member, IMPORTANT INFORMATION, relevant to YOUR Claim, is contained on this
More informationA Guide to. Making a Claim
A Guide to Making a Claim Reporting Claims Should you wish to make a claim or you feel that a claim may possibly be made against you please report the claim as soon as you are able as all insurers require
More informationClaim form - Business trip
Claim form - Business trip Illness, injury, accident, repatriation, personal assistance Policyholder Claim no. (policy no. and date of claim) Company contact person Company name VAT no. Company address
More informationIn the event of a claim, contact our 24-hour helpline numbers
CLAIMS FORM FOR GROUP TRAVEL INSURANCE(AIR ASIA) Claimant s Name : Claimant s Address: Phone No.(Mobile): Phone No.(Res) : E-mail ID: PNR : Policy Start Date : dd/mm/yyyy Policy End Date : dd/mm/yyyy In
More informationCombined Insurance Claim Form
Combined Insurance Claim Form Important Instructions on How to Complete the Attached Claim Form and How We Assess Claims Please read these important instructions on how to complete the attached Claim Form.
More informationMacquarie Life Total Permanent Disability (TPD): Claimant s Statement
Macquarie Life Total Permanent Disability (TPD): Claimant s ment Filling in this statement Please complete all sections, use black ink and mark boxes like this with an X. 1 May we disclose information
More informationPUBLIC/PERSONAL LIABILITY CLAIM FORM
ACE Insurance Limited PUBLIC/PERSONAL LIABILITY CLAIM FORM McKenna Hampton Pty Ltd "Kandahar House" Level 1, 41-43 Ord Street West Perth WA 6005 PO Box 204, West Perth WA 6872 Phone: 08 6142 0000 Fax:
More informationApplication for Benefits under the Motor Accidents (Compensation) Act Fatal Accident Application
Application for Benefits under the Motor Accidents (Compensation) Act Fatal Accident Application Losing a family member in a motor vehicle accident is a traumatic and difficult experience. The Motor Accidents
More information1. Personal Statement
journey injury claim form WFI Insurance Limited, ABN 24 000 036 279, AFS Licence no. 241461, Freecall 1300 651 654 IMPORTANT INFORMATION - Read before completing this form. (The issuing of this form is
More informationPersonal Accident / Sickness Claim Form
Personal Accident / Sickness Claim form All relevant sections are to be answered in full. Please print your answers. The company does not admit liability by the issue of this form. It is issued to enable
More informationCLAIM REPORT FORM CLAIM NUMBER: Claim Report Date / /
CLAIM NUMBER: Mil, --/--/2010 CLAIM REPORT FORM Claim Report Date Claimant surname Claimant name Telephone Number COMPLETE IN CAPITAL LETTERS Europäische Reiseversicherung AG Registered Office Rosenheimer
More informationReliance Inland Travel Care Policy Claim Form For Group Travel Insurance
Reliance Inland Travel Care Policy Claim Form For Group Travel Insurance IMPORTANT: Please contact our 24-hour helpline/toll Free (RGICL Call Center) for intimating a Claim Certificate/Policy No. Period
More informationTitle Given name/s Surname Date of birth. Postal address Suburb City Postcode
Claim Form Submit your claim to CoverMore by: Post: CoverMore Claims Department PO Box 105 203, Auckland 1143 Email: claims@covermore.co.nz NB: Original documentation will be required in order to finalise
More informationSECTION ONE: POLICY AND PERSONAL INFORMATION - ALL QUESTIONS REQUIRE COMPLETION. Name of Insured Company
Sydney Level 4, 33 York Street Sydney NSW 2000 GPO Box 4213, Sydney, NSW, 2001 T: +61 2 9251 8700 F: +61 2 9252 4385 ABN: 26 053 335 952 AFS Licence : 238621 Email: claims@acchealth.com.au www.acchealth.com.au
More informationCHECKLIST OF DOCUMENTS REQUIRED
M EMERGENCY MEDICAL EXPENSES, HOSPITAL INCONVENIENCE BENEFIT Travel Claims Facilities 1 Tower View Kings Hill, West Malling Kent ME19 4UY Tel: 0845 370 7187 Fax: 0870 620 5001 Email: claims@tif-plc.co.uk
More informationPersonal Injury Claim Form
ACE Insurance Limited ABN 23 001 642 020 28-34 O Connell Street Sydney NSW 2000 Australia GPO Box 4065 Sydney NSW 2001 Australia 1800 688 640 claims phone 1800 815 675 customer service +61 (0)2 9231 3697
More informationGroup Journey Injury Insurance
Group Journey Injury Insurance Claim form All relevant sections are to be answered in full. Please print your answers. Zurich does not admit liability by the issue of this form. It is issued to enable
More information