Trip Cancellation/Interruption Form

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IMPORTANT NOTICE: Written notice of claim must be provided within 90 days of the loss. Written proof of loss must be provided within 90 after the date of loss. If it cannot be provided within that time period, it should be sent as soon as reasonably possible. In no event, except in the absence of legal capacity, will proof of loss be accepted more than one year from the date it was otherwise required.

Please complete Sections A,B,C & D. Complete a separate Claim Form for each individual.

Section A. Insured Information
Please provide telephone numbers, with country and city codes.
Section B. Travel Information
Section C. Reason for Claim (provide additional pages if necessary):
Section D. Physician or Provider
Hospital confinement dates:
Total Disability dates:
Partial Disability dates: