Travel Insurance Claim Form

Transcription

1 CLAIMAINTS DETAILS Policy Number Departure Date Return Date Title First Name Surname ID / Passport Number Address Mobile Number Business Contact No Home Contact No Fax No Postal Address Postal Code Physical Address Physical Address Code Was your Airline Ticket purchased by Cash Credit Card Voyager Miles Medical Aid Scheme Membership Number Other Insurance Policies Yes / No ( Please include all Short Term All Risk Insurance Policies) Insurance Company Policy Number 1

2 BANKING DETAILS FOR CLAIM PAYMENTS Bank Account No Bank Name Branch Code Branch Name Account Type Name of Account Holder Copy of a cancelled cheque / bank statement is required in order to validate banking details CLAIM INFORMATION Date of Incident / Loss Country of Incident / Loss Did you notify the Assistance Company Yes / No Assistance Company Reference Number TYPE OF CLAIM Emergency Medical & Related Expenses Bidvest Medical Assistance & Travel Services Cancellation, Curtailment & Related Expenses Baggage & Related Expenses Legal Liability & Related Expenses Incidental Damage / Loss Credit Card Top Up Excess Waiver Declaration / Authority 1. I/We hereby declare that all information, answers, and documentation given in connection with this claim are true and correct to the best of my/our knowledge and belief. I/We have not omitted any material information, which could affect the underwriter s judgement of the claim. 2. I/We understand that the information on this form will be passed to or used by us and our appointed claims handling agent, this includes underwriting, processing, handling claims and preventing fraud. 3. I/We authorise any doctor, hospital or other organisation or person having any records or information concerning my medical history or treatment to furnish such records of information as may be requested by us or our claims handling agent. I am also aware that such information/records are relevant in the evaluation of my claim and that non-submission could prejudice my claim. A photocopy of this authorisation shall be considered as effective and valid as the original. 4. I/We further declare that I am/we are aware that any misrepresentation and/or non-disclosure in respect of information provided herein shall render my/our claim null and void. 5. I/We declare that I/We have read the policy wording. I/We read and fully understand the declaration above. All Insured Persons claiming must sign. 2

3 NAME SURNAME DATE OF BIRTH SIGNATURE EMERGENCY MEDICAL & RELATED EXPENSES Please attach the following supporting documentation for successful claims registration and assessment. Original travel tickets / public conveyance tickets for Your booked itinerary (including tickets from/back to your Home Country) Copy of your Travel Insurance Policy Certificate We require a 6 months medical history from Your usual medical practitioner Detailed medical report including diagnosis from the treating medical practitioner abroad Incident report/police report where applicable All original invoices/receipts for expenses incurred If a claim is submitted on behalf of a deceased insured, We will require certified copies of the death certificate. If the insured passed away due to illness rather than as a result of injury, We require a medical certificate to be completed by the deceased s usual medical practitioner Medical Questionnaire if Pre Existing Conditions is applicable **A Policy Excess is Applicable in Respect of all Outpatient claims. B) Additional Information Required: Did you consult a Medical Practitioner whilst on your Insured Journey? Y/N Please provide details of the Medical practitioner you consulted: o Name, Surname o Telephone Number o Address Were you hospitalised whilst on your Insured Journey? Y/N Please provide the following information? o Hospital Name o Hospital Address o Hospital Telephone Number o Date of Admission 3

4 o Date of discharge Did you seek Medical Treatment as a result of Illness OR Injury Have you been treated for this Illness or Injury or a related Illness or Injury before? Y/N If yes, please provide a report from your Local Medical Practitioner stating what treatment you received during the last 6 months before the inception date of your Insured Journey Did you seek Medical Treatment as a result of a Leisure and Sporting Activity? Y/N If yes, please specify the activity? Please indicate if you participated on a Professional Level? If yes, please specify the level? C) Full description of Illness / Injury and details of any third party involved including diagnosis received. D) Medical Questionnaire Authorisation for Disclosure of Medical History and Related Information ( to be completed by the Insured Person) I hereby authorise all information relating to my medical history, records and assessments to Bidvest Insurance and or their representatives. I understand that the information will be used solely when assessing medical claims ad will be treated as confidential information. Insured Name: Insured Surname: Journey Departure Date: Journey Return Date: Insured Signature: Date: Medical History and Information ( to be completed by your local treating medical practitioner ) The above mentioned Insured Person, also Your patient purchased travel insurance for his International Journey as indicated above and subsequently submitted a medical claim with Bidvest Insurance. In order to assess the claim accordingly we request that you provide Bidvest Insurance with a comprehensive medical report of the patient that received medical treatment or advice for any illness, injury or disease during the past 6 months before the policy issue date. Please provide details of all conditions for which your patients has received medical treatment / advice in the past 6 months Date: Diagnosis: Treatment: Medication: 4

5 Notes: Please provide details of all conditions for which your patients is currently receiving medical treatment / advice Date: Diagnosis: Treatment: Medication: Notes: Period for which you have been treating your patient? ( Years, Months, Days) Date of last examination? In your professional and medical opinion was your patient medically and physically fit to travel on an international journey? Y/N If No, please provide reasons to us. Dr Name Dr Surname Practice No Telephone: Address Dr Signature Date 5

6 Bidvest Medical and Travel Assistance Services Please attach the following supporting documentation for successful claims registration and assessment. Original travel tickets / public conveyance tickets for Your booked itinerary (including tickets from/back to your Home Country) Copy of your Travel Insurance Policy Certificate We require a 6 months medical history from Your usual medical practitioner Detailed medical report including diagnosis from the treating medical practitioner abroad Incident report/police report where applicable All original invoices/receipts for expenses incurred If a claim is submitted on behalf of a deceased insured, We will require certified copies of the death certificate. If the insured passed away due to illness rather than as a result of injury, We require a medical certificate to be completed by the deceased s usual medical practitioner. B) Please advise what you are claiming for: C) Please provide us with detailed information of the claim? 6

7 Cancellation, Curtailment, Postponement, Denied Visa, Travel Supplier Insolvency, Missed Connection, Journey Replacement, Travel Delay, Replacement Personnel Please attach the following supporting documentation for successful claims registration and assessment.. Copy of your Travel Insurance Policy Certificate Unused travel tickets / public conveyance tickets for your booked itinerary (including tickets from/back to your Home Country) Copy of the Holiday / Flight Invoice that will indicate original amount paid A letter from the provider confirming their cancellation/refund policy and whether any amount was refunded to you If your claim is based on medical grounds, including death, the medical questionnaire must be completed by the local treating medical practitioner of the individual whose condition has led to the submission of the claim If your claim is due to death we require a certified copy of the death certificate. If this claim is being submitted as a result of an injury please provide a full description of the incident leading to the injury. If a third party was involved please provide their details. If your claim is due to termination we require a letter from your former employer which confirms that you have been made redundant and are due to receive a payment under current legislation, the position you held and your length of service. If the claim is due to Denied Visa Application, we require a letter from the appropriate authority stating the reason for decline If the claim is a result of Travel Insurance Supplier we require correspondence confirming bankruptcy and or financial default If claim is a result of Burglary, we require an assessment report form your all risk insurer and a police report If your claim is a result of Travel Delay or Missed Connection, we require Proof of all expenses incurred aswell as a written report from the transport provider stating reason for delay / missed connection and duration of delay / missed connection B) Please advise what you are claiming for: C) Please provide us with detailed information of the claim? 7

8 Baggage and Related Expenses Please attach the following supporting documentation for successful claims registration and assessment Copy of Your International Flight tickets purchased for Your booked itinerary The original travel provider invoice (original amount paid and any refund amount due) A police report, if property was lost or stolen other than whilst in the custody of a Carrier If the claim is for property lost, stolen or damaged whilst in the custody of a Carrier, please forward the report issued by the Carrier or their agent, written confirmation from the Carrier that no payment has been issued to You Baggage delay claims only: receipts for necessary purchases of essential clothing and toiletries and the Carriers confirmation of the incident and the date and time Your luggage arrived Damage claims only: Please provide an estimate for repair. If the damage is beyond repair We require written confirmation from a relevant tradesman. Please retain all damaged items as We may require them to be forwarded to Our offices In respect of jewellery claims, original or certified copies of evaluation certificates issued prior to the Commencement of the Insured Journey is required Receipts for new items purchased and replacement quotes for items claimed Baggage loss/damage/delay by a Carrier must be reported to the carrier within 24(twenty four) hours, or alternatively as soon as reasonably possible A claim must be filed with the Carrier first. Any loss not caused by a Carrier must be reported to the appropriate authorities within 24(twenty four) hours of the loss or alternatively as soon as reasonably possible. B) Please advise what you are claiming for: C) Please provide us with detailed information of the claim? 8

9 Legal Liability and Related Expenses Please attach the following supporting documentation for successful claims registration and assessment Copy of your International Flight tickets purchased for Your booked itinerary The original travel provider invoice (original amount paid and any refund amount due) Details of Your regular medical practitioner and any specialists from whom You have received treatment Death Certificate detailing cause of death Inquest and Post Mortem Reports Police Report if death is due to a motor accident. The Police Station and Reference number if death is the subject of criminal investigation All correspondence received from a 3rd party Identity Documentation B) Please advise what you are claiming for: C) Please provide us with detailed information of the claim? 9