Travel Protection Claim Form

Note type of claim to be processed:

I. General Information

Plan Purchased *

Policy ID Number *

Travel Company Name *

Date of Booking *

Trip Departure Date *

Trip Return Date *

Reason for Claim: *

II. Insured Information

Primary Insured Name *

Primary Insured Date of Birth *

Parent or Guardian (if under 18)

Home Phone # *

Please provide telephone numbers with country and city codes.

Work Phone # *

Please provide telephone numbers with country and city codes.

Email *

Preferred Contact Method *

Other Coverage Information

Do you have any other insurance? (i.e. health or homeowners insurance)

If yes, please provide source of insurance

Are claim expenses recoverable from another source?

If yes, please provide details and amounts:

Name and addresses of all physicians consulted

Primary Care Physician *

PCP City: *

PCP State: *

PCP Phone#: *

Name: *

Date of treatment: *

Address: *

Name: *

Date of treatment: *

Address: *

What operation was performed? *

If in a hospital, which one:

From

To *

Email