American Express Platinum Card Claim Form

Important Information American Express Platinum Card Claim Form Please ensure this form is completed in all Parts applicable to your claim. Supporting documentation required is detailed in each Part. The issue and acceptance of this form does not constitute an admission of liability by the company or a waiver of its rights. Policy and Claimant Details Name of Cardmember ALL QUESTIONS IN THIS SECTION MUST BE ANSWERED Name of claimant Date of birth / / Occupation Policy number AGRG 381911 Card number 3 7 7 4 Address Telephone home Email Business Mobile Travel agent Date of booking travel / / arrangements Date of departure / / Date of return / / Electronic Funds Transfer Details Following ACE approval of your claim, where applicable some benefits may be paid direct to you, otherwise benefits will be paid to your American Express Card. Should you wish to have your claim benefits paid directly into your bank account, please provide the following details: (For those sections where this option does not apply payment will be credited to your American Express Platinum Account or to your Membership Rewards points account (in points) subject to your original form of payment.) Bank name Bank address Bank account holders name Bank account number Pre-Existing Medical Conditions Please attach hereto a copy of correspondence received from AXA Assistance Limited, if any. Acceptance number THE PRIVACY CONSENT AND DECLARATION MUST BE COMPLETED AND RETURNED PLEASE ONLY PRINT THOSE PAGES RELEVANT TO YOUR CLAIM

SECTION A - TRANSPORT ACCIDENT COVER (LOSS OF LIFE) 1. Certified copy of the death certificate. 2. A full copy of coroner s report and findings and all accident reports. 3. Proof of American Express Platinum Card Membership eg. copy of Card statement. What was the cause of death? When did the death occur? Date / / Time am/pm Was the deceased a passenger? Yes No If no, please Specify: Was a coronial inquest held or is one to be held? Yes No If so, give details: Date of birth / / Relationship to the Cardmember Name, address and phone number of usual doctor How long was the patient known to the doctor? SECTION A TRANSPORT ACCIDENT COVER (ACCIDENTAL BODILY INJURY - DISMEMBERMENT) 1. Certified copy of all medical reports. 2. A copy of all accident reports from the transport provider. 3. Proof of American Express Platinum Card Membership eg. copy of Card statement. What was the cause of injury? When did the accident occur? Date / / Time am/pm What are the injuries you sustained which occurred within 100 days of the accident? Date of birth / / Relationship to the Cardmember Name, address and phone number of usual doctor How long was the patient known to the doctor?

SECTION B CARD ACCOUNT BALANCE WAIVER COVER 1. Full copies of your American Express Platinum Card statements covering the period 90 days prior to your accident. The information that you have provided in SECTION A of this claim should be sufficient for us to be able to process your claim, however we will contact you should any other information or documentation be required. Should you wish to add further information to support your claim, please do so here and attach any documentation that is directly applicable to this section of your claim.

SECTION C - TRAVEL INCONVENIENCE COVER 1. Original receipts and copies of the Platinum Card Statement(s) relating to additional expenses incurred for hotel accommodation, restaurant meals or refreshments, emergency purchase of essential clothing and requisites. These expenses must be charged to your American Express Platinum Card. 2. Letter from airline confirming basis of delay, duration or cancellation. 3. Copy of the property irregularity report from the airline. 4. A full copy of your itinerary. 5. Proof of American Express Platinum Card Membership eg. copy of Card statement. Failure to provide these items may result in delays in processing your claim. Date(s) expenses incurred From / / To / / Reason(s) for incurring additional accommodation, restaurant meals, refreshments, emergency purchase of clothing or requisite expenses 1. Delayed flight 2. Missed connection 3. Luggage delay (more than 8 hours) 4. Extended luggage delay (more than 48 hours) List specifically the additional accommodation expenses Details Currency Amount in NZ Total Full details of flight number, departure airport, destination, scheduled flight times & arrival airport Flight no. Dep. airport Destination Flight times Arrival airport Full details of the delay or loss incurred Full details of expenses for which reimbursement is claimed

SECTION D - MEDICAL EMERGENCY EXPENSES COVER 1. Original doctor s/hospital accounts and receipts. 2. Details relating to any medical benefit refunds available against any other health insurance, i.e. Southern Cross 3. Original doctor s certificate verifying nature of complaint suffered by you. 4. Proof of American Express Platinum Card Membership eg. copy of Card statement. 5. Details of prior authorisation of expenses provided by Emergency Assistance Company (eg. date of telephone call; name of authorising person; authorisation reference). Type of injury or sickness Date injury or sickness commenced / / Give full details Name of doctor or hospital Date of first medical consultation / / Details of other treatment by doctors/hospital Date in hospital Admitted / / am/pm Discharged / / am/pm List the country(ies) and the currency in which you incurred the medical costs Country Provider Currency Charge Country Provider Currency Charge Country Provider Currency Charge Have you ever suffered from the same or similar complaint in the past? Yes No If Yes, give details, dates, names and addresses of treating physicians Name, address and phone number of usual doctor How long has the patient been known to the doctor? Do you have any other insurance policy that covers you for this event? Yes No Details

SECTION E - BAGGAGE, MONEY, DOCUMENTS COVER 1. Written report or letter from authority (e.g. police, airline) regarding the loss. 2. Receipts, guarantee certificates, instruction manuals, valuation certificates, bankcard or credit card vouchers or other proof of purchase for items claimed. 3. Bank statements, transaction receipts or other proof of cash claimed. 4. Written quotations for replacement of items claimed. 5. Proof of American Express Platinum Card Membership eg. copy of Card statement. Date loss/damage occurred / / Time am/pm Date loss/damage reported / / Time am/pm Give full details of how losses, damage or thefts occurred (Detail each event) Loss/damage reported to (police, airline or other authority) Name Were articles lost/damaged by carrier? (e.g. airline) Yes No Name Have you yet lodged a claim or complaint against any carrier/airline or other authority or against any individual responsible for the loss or damage to your property? If so, give details and attach copies of correspondence. If not, you should proceed to claim with your carrier/ airline before submitting your claim to ACE Airline Claim Number Contact Details Note: The carrier is liable for any goods in their custody for loss or damage, you should claim with them first What action was taken to recover lost/damaged/stolen items? Are any of the items covered by other insurance? Yes No If yes which company Policy number Were all the missing articles your property? Yes No If not, give details Other comments (if necessary) Description and size of suitcase in which missing goods were carried Full details of articles claimed (including value of cases) Name and address from whom goods were purchased Original date of purchase Replacement price Amount Claimed NZ

SECTION F - TRAVEL CANCELLATION COVER 1. Doctor s/hospital certificate specifying exact nature of condition suffered by injured/sick person. 2. Letter from travel agent verifying total cost of journey, value of unused portion of journey, cancellation charges incurred and total amount of refund received. 3. Proof of American Express Platinum Card Membership eg. copy of Card statement. What was the reason you could not commence or complete your proposed journey? (Please provide a full explanation) Was the cancellation as a result of injury/sickness to yourself? Yes No Was the cancellation as a result of injury/sickness to a close relative? Yes No If so name, address and relationship Nature of condition the injured/sick person is suffering from Date of first medical treatment / / Has the injured/sick person had a similar condition in the past? Yes No If yes, please provide full details Name, address and phone number of injured/sick person s usual doctor Amount of deposit paid and date paid Date / / Balance of full fare and date paid Date / / Date you advised travel agent to cancel bookings / / Value of forfeited portion of journey (if applicable) Refund received on cancellation Date / / Full amount being claimed

SECTION G - PERSONAL LIABILITY COVER (EXCLUDING MOTOR VEHICLE) 1. Letters or demands of a claim made against you. 2. Evidence of any amounts being claimed must be provided. 3. Proof of American Express Platinum Card Membership eg. copy of Card statement. Bodily injury provide relevant details name and address of injured party and details of injury and how this occurred Date / / Time am/pm Damage to property list all property damage together with name and address of party claiming damage against you Date / / Time am/pm Is the injury or damage related to a family member or any person under a contract of service or apprenticeship with you? Yes No If yes, please provide name and contact details Do you consider you were at fault? Yes No Please provide details of circumstances that gave rise to the event YOU MUST NOT ADMIT LIABILITY, MAKE ANY PROMISE, PAYMENT OR SETTLEMENT WITHOUT ACE INSURANCE S WRITTEN CONSENT. SECTION H HIJACK AND DETENTION COVER 1. Written confirmation from police or airline, or printed media reports of the event. 2. Receipts for expenses such as accommodation, meals, travel costs which were not part of the original intended journey. 3. Proof of American Express Platinum Card Membership eg. Copy of Card statement. 4. A full copy of your travel itinerary. Date of event / / Location/country Describe exactly what happened How long were you detained Itemise the expenses incurred by your close relative Description Currency Amount in NZ Total

SECTION I - PURCHASE PROTECTION COVER 1. Receipt(s) for proof of purchase. 2. A full copy of your American Express statement showing purchase. 3. A full copy of the police report if item(s) were stolen. 4. If your item(s) were damaged, a quote to repair the damaged item(s). Full name of Cardmember Address Phone number(s) Email address Date damage/theft occurred / / Time: am/pm Date theft reported / / Time: am/pm Have you previously claimed under Section I within the last 365 days? Yes No If yes, please provide details of such a claim Please provide full details of how and where the damage or theft occurred for this claim (Detail each event) SECTION J - BUYER S ADVANTAGE COVER 1. Receipt/s of proof of purchase. 2. A full copy of your American Express statement showing purchase. 3. Copy of original manufacturer s warranty. 4. If your item/s was damaged, a quote to repair the damaged item/s. Type of item Purchase date / / Manufacturer Manufacturer s serial number Item s purchase price (including GST) Is the damage repairable? Yes No Please provide full details of the breakdown or defect/repairs required Other Insurance You must complete this section in full. If you do not it will delay settlement of your claim Do you have any other insurance that will cover the loss? Yes No If yes, please provide the name and address of your insurer PLEASE NOTE THAT UPON REQUEST YOU MUST DELIVER THE DAMAGED ITEM/S DIRECTLY TO OUR ADDRESS.

SECTION K LOSS DAMAGE WAIVER COVER 1. Copy of the full rental agreement including terms and conditions of hire. 2. Copy of any repair invoice relating to the damage to the rental vehicle. 3. Copy of any correspondence received from any other insurance company, third party or police/traffic authority involved. Name of driver at time of event Date of birth / / (Limited to persons aged over 21 years but under 74 years of age) Date of accident / / Time am/pm Location of accident Did police attend? Yes No Please provide details and attach a copy of the police report Name of person who is considered at fault. Please provide details Have you claimed under this Section previously? Yes No Please provide details of previous claim YOU MUST NOT ADMIT LIABILITY, MAKE ANY PROMISE, PAYMENT OR SETTLEMENT WITHOUT ACE INSURANCE S WRITTEN CONSENT LIMITED TO A MAXIMUM OF 2 CLAIMS PER 365 DAYS

ADDITIONAL COMMENTS Should you require further space please use this page

PRIVACY CONSENT ACE Insurance Limited ( ACE ) collects, uses and retains your personal information only in accordance with the principles in the Privacy Act 1993. A copy of our Privacy Statement, which expands upon our privacy obligations and provides further information on your rights to access your personal information held by us is available on our website or by contacting our Privacy Officer on +64 (9) 377 1459. Your personal information will be used by ACE, or any third party that ACE provides the information to, for the purpose of assessing your claim or your entitlement to benefits and, if the claim is accepted, for administration of the claim and for planning, product development and research purposes. Your personal information includes: (a) (b) (c) (d) (e) (f) any information provided in relation to your claim; any information that is health information or sensitive information; any other personal information that you may provide to ACE or its third party contractors; any information relating to the insurance policy on your life, including terms and conditions and claims history; details of your employment including position, period of employment, remuneration, hours worked and duties performed; and any other information relating to your income and solvency. To process your claim ACE may need to collect your personal information from third parties such as your insurance broker, claims reference services, government organisations (for example social security agencies or taxation offices), any forensic accountant retained by ACE, your employers (past and present), your accountant and any businesses which provide information about the commercial activities of persons or, if you are, or have been, bankrupt the trustee of your estate (the Parties ). You agree that the Parties may disclose your personal information to ACE. ACE may disclose your personal information, including health and sensitive information, to third parties, including contractors and contracted service providers engaged by us to deliver our services (such as assessors), other companies in the ACE group, other insurers, our reinsurers, and government agencies (where we are compelled to by law). These third parties may be located outside New Zealand. ACE may also disclose your personal information to witnesses in respect to your claim. You agree to us using and disclosing your personal information pursuant to ACE s Privacy Statement and this Claim Privacy Consent. In the event of any conflict between the documents, this Claims Privacy Consent shall be determinative. This consent remains valid unless you alter or revoke it by giving written notice to our privacy officer. If you do not consent to the terms of this Claims Privacy Consent or revoke your consent, ACE may not be able to process or assess your claim. DECLARATION I declare that to the best of my knowledge the particulars are true and correct, and that I have not withheld any information that is relevant to this claim. I will notify ACE immediately if any of the lost or stolen property mentioned in this claim is subsequently recovered and surrender the property or refund the money received in compensation to ACE. I accept that wilful or reckless exaggeration or inflation of the amount(s) claimed will result in automatic forfeiture of the claim and the policy shall be void. I request and authorise any hospital, doctor, or other person who has attended or examined me to furnish to ACE or its representative all information concerning any illness or injury suffered, medical history, consultations, prescriptions, or treatments including X-ray plates and copies of all hospital or medical records, so that they may be included as a part of the proofs of the claim submitted. A photocopy of this authorisation will be considered as effective and valid as the original. I authorise the disclosure to ACE of personal information held by any person or organisation regarding or affecting this claim and authorise ACE to release to any other relevant person or organisation information regarding or affecting this claim. Signature of Claimant: Name of Claimant: Address: Date: Signature of Witness: Name of Witness: Address: Date: THE PERSONAL INFORMATION COLLECTED ON THIS CLAIM FORM WILL BE HELD BY ACE INSURANCE LIMITED YOU HAVE RIGHTS OF ACCESS TO AND CORRECTIONS OF INFORMATION UNDER THE PRIVACY ACT 1993