Claim Form - Travel Name of Insured(Required) PhoneEmail Departure Date(Required) DD slash MM slash YYYY Return Date(Required) DD slash MM slash YYYY Departure City Destination City Departure Country Destination Country Date of Incident(Required) DD slash MM slash YYYY Incident City Incident Country Description of Incident(Required)Was the Emergency Assistance Company contacted?N/AYesNoIf an illness, has the claimant suffered this complaint before?N/AYesNoDetails of Medical Expenses IncurredDate of ExpenseDescriptionAmount Add RemoveDescription of Property Lost or Damaged(Required)DescriptionReplacement Value Add RemoveWas the incident reported to the police/authorities? Yes No If Yes, provide details Have you incurred additional travel expenses? Yes No Additional ExpensesDate of ExpenseDescriptionAmount Add RemoveHave you been involved in a motor vehicle incident? Yes No Name of Hire Car Company Driver's Name First Last Vehicle ExcessRepair CostsAmount Being Claimed Add RemoveAdditional InformationConsent(Required) I/We declare that the whole of the above information and answers are true in every detail and no information has been withheld.Name(Required) First Last Date(Required) DD slash MM slash YYYY File Drop files here or Select files Accepted file types: png, jpg, pdf, doc, docx, Max. file size: 16 MB. CAPTCHA
