ESIS Web Form – Soteria365

Policy Number *

Was the person who became sick or injured listed on the policy certificate *

Which of the following best describes what happened: *

One or more of us were injured in an accident, mishap or some other "external" event. (e.g. fell down stairs)
One of us was injured, but there was not obvious cause (e.g. Woke up with a bad back)
One of us went to the dentist for emergency dental treatment
One or more or us fell ill

Date and Time the injury occured:

Date

Time

Name and place where the injury occurred:

If the place does not have a specific name, please provide a general description.

Address of the place where the injury occurred:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Which member(s) of your traveling party was injured?

Please check all that apply.

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