Travel Insurance Claim Form

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Austen Phelps
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1 Travel Insurance Claim Form Instructions: i. ii. iii. iv. A. GENERAL 1. Policy No 2. Certificate No. 3. Full Name of Insured (as per Identification Card) Claim No. Please answer all relevant questions on the claim form; leaving items blank, using ticks, dashes and N/A may cause delay in processing. If insufficient space is provided for your answer, please continue on a separate sheet. This form is sent without prejudice to the terms and conditions of the Policy and should not be regarded as a waiver by the Company of any breach of the conditions the Insured may have committed. The acceptance of this form is not in itself an admission of Policy Liability on the part of Zurich General Insurance Malaysia Berhad. Please complete the General section followed by the relevant section(s) to which your claim(s) relate(s). 4. Nationality 5. Address 6. Contact No Have you received any payments from other insurance company/carrier/other parties or refund obtained for this loss? Yes No (If yes, please state amount received, name of insurance company and policy no or name of carrier/other parties/refund company) B. DETAILS OF CLAIMANT (If different from Insured) 1. Full Name of Claimant (as per Identification Card) 2. Relationship to Insured 3. Nationality C. ACCIDENT RELATED CLAIM ONLY 1. and Time of Accident 2. Place of accident 3. Circumstances of Accident 4. Details of injuries sustained or cause of death 5. Please furnish the details of any treatment in connection with this injury Name of Hospital / Clinic Treatment / Hospitalization (dd/mm/yy) D. ILLNESS RELATED CLAIM ONLY 1. of onset of illness 2. Nature of illness 3. Have you ever been treated for this illness before? Yes, first date of consultation No (If yes, please state Name & Address of your regular physician in Malaysia) 2277/2/P/G/S/M

2 4. Please furnish the details of any treatment in connection with this illness Name of Hospital / Clinic Treatment / Hospitalization (dd/mm/yy) E. BAGGAGE DELAY 1. Period of delay 2. Did you report the loss to the carrier? Yes No (if yes, please provide date reported and copy of carrier report) 3. Please provide detail:- Flight No. Arrival Receipt of Baggage (dd/mm/yy) Time (hh/mm am/pm) (dd/mm/yy) Time (hh/mm am/pm) F. LOSS OF BAGGAGE & PERSONAL EFFECTS / PERSONAL MONEY & DOCUMENTS / PERSONAL CREDIT THEFT / GOLF EQUIPMENT 1. Please tick the appropriate box: Damage/Loss of Personal Effects Loss of Travel Document Baggage Loss Loss Of Money 2. and time of loss / damage 3. Place of loss / damage 4. Full circumstances of loss / damage or delay 5. Did you report the loss to the police/carrier/issuing bank? Yes No (if yes, please provide date reported and copy of the report) 6. Please provide detail:- Details of item(s) lost or damaged including make / model (Please provide original purchase/repair invoices/receipts) Place d Price Amount claimed 7. Please provide detail:- Cash / Banknotes / Traveller s cheque Amount (RM) Amount in foreign currency Total amount claimed G. TRAVEL DELAY / CHARTERED FLIGHT 1. Reason for delay 2. Period of delay (must at least be 6 hours for Travel delay and 10 hours for Chartered Flight, from the time specified in the travel itinerary)

3 3. Please provide detail:- Flight No Airport of departure Original scheduled departure Actual departure From To Time From To Time H. LOSS OF DEPOSIT OR CANCELLATION COVER / CURTAILMENT 1. Claim for (tick where appropriate): Cancellation Curtailment 2. of cancellation / Arrival home if curtailed 3. of booking 4. Reason for cancellation / curtailment 5. Name of sick or injured person and relationship to Insured 6. Please provide detail:- Nature of Expenditure I. OVERBOOKED FLIGHT / TRAVEL MISCONNECTION / TRAVEL REROUTE 1. Please provide detail:- Flight No Airport of departure Original scheduled departure Actual departure From To Time From To Time J. RENTAL CAR EXCESS COVER 1. and time of accident 2. Circumstances of accident 3. Did you report the loss to the police? Yes No (if yes, please provide date reported and copy of police report) 4. Excess amount paid K. HOME CARE BENEFIT 1. and time of fire / theft 2. Circumstances of loss 3. Did you report the loss to the police? Yes No (if yes, please provide date reported and copy of police report) 4. Total amount of loss

4 5. Please provide detail:- No of items Details of item(s) lost or damaged including make / model, etc. Place d Price Amount claimed L. OTHER BENEFITS 1. Please tick the appropriate box: Missed Departure Cancellation due to delay Compassionate Visit Child Care Domestic Pet Care Loss of use of Hotel Facilities Emergency Telephone Charges Loss of Use of Entertainment Ticket Loss of Deposit or Full Payment due to Insolvency of Airlines Others, please state 2. and Time of loss 3. Place of loss / damage 4. Full circumstances of loss 5. Please provide detail:- Nature of Expenditure M. DECLARATION AND AUTHORIZATION I declare that the answers given above are true and complete to the best of my knowledge and belief. I agree that if any false or fraudulent statement or any concealment of material fact, the Policy shall be void and my right to compensation absolutely forfeited I hereby irrevocably authorize any organization, institution, or individual that has any record or knowledge of my health and medical history or treatment or advice that has been or may hereafter be consulted,other personal information or details of related accident/ injury, to disclose to Zurich General Insurance Malaysia Berhad or its representative such information. I agree that Zurich General Insurance Malaysia Berhad or its representative may use or disclose any of the information collected or held to third parties (within or outside Malaysia, including Zurich General Insurance Malaysia Berhad parent company, subsidiaries or any other associated companies within ZZurich General Insurance Malaysia Berhad, reinsurers, medical examiners, claims investigators and industry associations/federations etc.) in relation to this claim. This authorization shall bind my/the Assured s/insured s successors and assigns and remain valid notwithstanding my/assured s/insured s incapacity in so far as legally possible. A photocopy of this authorization shall be valid as the original. I agree that in the event I make, or have in the past made, any false or untrue statement and/or suppressed and/or concealed any material facts in respect of my/the insured s condition, Zurich General Insurance Malaysia Berhad shall absolutely forfeit my/the Insured s/assured s right to compensation and further reserves the right to recover any amounts paid earlier as a result thereof. Name & Signature of Claimant Signature of Policyholder/Insured and Company s Rubber stamp * It is agreed that English version will be prevail if there is any ambiguity in English provisions or Bahasa Malaysia provisions.a. NOTE : Please refer to our website at for details of our Data Privacy Notice

5 MEDICAL CERTIFICATE (to be completed by the attending doctor) Note: a) This Medical Certificate must be completed by Insured Person s regular doctor pertaining to the medical history prior to commencement of the journey/attending physician in respect of claims for personal accident / medical and other expenses / hospital allowance / emergency medical evacuation and repatriation / loss of deposit or cancellation / curtailment. b) Any charges for completion of this form are the responsibility of the Insured/Claimant. 1. Name of Patient / Insured: 2. NRIC No./ Passport No.: 3. Are you the patient s regular doctor? 4. For how long have you known the patient? Yes No 5. the patient first consulted you: 6. you last saw him /her professionaly: 7. Has the patient suffer any physical defects, deformities, congenital or hereditary disease? Yes (If yes, please give details) No 8. Type of treatment Emergency Elective Expected 9. The diagnosis of this condition is caused by Accident Illness 10. and Time of Accident / Onset of Illness AM / PM 11. Period of admission to hospital From to 12. Circumstances of Accident / Illness in detail 13. Description of Medical Condition 14. Nature of Treatment given 15. Please state from the past records or from your personal knowledge, details of all illness, accidents / surgical operations or disease from which the patient has suffered or for which he/she has been treated at your clinic Complaint & Symptoms Diagnosis Treatment Name of medicine prescribed 16. I hereby certify that I have personally examined and treated the Patient for his/her injuries/illness described above and that the facts as stated above represent my medical opinion of his/her condition Signature and Stamp of Attending Physician / Surgeon

6 DOCUMENTATION CHECKLIST Please refer to this checklist for your claim and attach all necessary documents as soon as possible. We may request further documents where necessary. DOCUMENTS REQUIRED FOR ALL CLAIMS * Completed and signed claim form * Airline tickets / boarding pass / electronic tickets * Travel itinerary * Electronic Fund Transfer (EFT) Authorization Form ACCIDENTAL DEATH/PERMANENT DISABLEMENT * Copy of Death Certificate * Copy of Detailed Post Mortem/Autopsy Report/Medical Report * Copy of police report/newspaper cutting on the alleged accident * Copy of Nominee s/claimant s Identity Card and Proof of Relationship * Letter of Administration / Distribution Order (if no Nomination / Nominee is below the age of 18 years) * Medical Specialist Report (Permanent Disablement case only) and assessment of the disability done at the end of 12 months after the date of accident OVERSEAS MEDICAL REIMBURSEMENT * Medical report / Diagnosis Note / Imaging / Lab report / other relevant documents from the attending doctor abroad * Original Hospital Bill / Medical Invoice & Payment Receipt * Original payment receipts for additional expenses claimed for additional travel and accommodation. OVERSEA HOSPITAL INCOME * Diagnosis Note from the attending doctor abroad stating the nature of injury/illness * Copy of Hospital Bill / Medical Invoice stating the period of hospitalization COMPASSIONATE VISIT / CHILD CARE BENEFIT * Copy of Hospital Billing Statement stating the period of hospitalization * Medical Report / Copy of Detailed Post Mortem Report / Copy of death certificate * Written advice from Medical Practitioner for the compassionate visit (travel from Malaysia) and proof of relationship * Original Receipt for travel and accommodation expenses incurred LOSS OF DEPOSIT OR CANCELLATION / CURTAILMENT * Travel Agency / Common Carrier terms and conditions documents * Written confirmation on the Cancellation and refund amount (if no refund, reason and proof) from Travel Agency / Common Carrier * Original Invoice and Payment Receipt (full amount paid) * Copy of Proof of Relationship * Medical Report/copy of Hospital Bill/Death Certificate * Police report and proof on the damaged property, if applicable * If due to adverse weather condition, written confirmation from Common Carrier * Court letter, if being called as a witness * Boarding Pass/copy of passport to confirm the actual date of arrival back to Malaysia, for Travel Curtailment. TRAVEL DELAY, REROUTE, OVERBOOKED, MISCONNECTION, CHARTERED FLIGHT * Written Confirmation from Common Carrier stating:- If delay: Period and Reason of Delay If reroute: Location and Reason of Reroute If overbooked: Reason and next flight arrangement (date and time) If misconnection: Flight details and actual departure time of connecting flight If chartered Flight: Flight details, reason of delay, next flight arrangement/alternative transportation available (date and time) BAGGAGE DELAY * Property Irregularity Report from Common Carrier * Written Confirmation / Baggage Return Delivery Note from Common Carrier stating the period of delay PERSONAL MONEY AND DOCUMENTS * Police Report stating the circumstances of loss and list of lost items * Original Receipt (additional accommodation, travel and communication expenses incurred in obtaining new travel documents) * For Money claim - currency exchange slip is required CHILD EDUCATION GRANT Proof of Relationship (Birth Certificate) FOLLOW UP TREATMENT IN MALAYSIA * Medical Report from attending doctor in Malaysia * Original Hospital Bill / Medical Invoice and Payment Receipts REPATRIATION OF MORTAL REMAINS * Copy of Death Certificate * Original Payment Receipt for the funeral / burial expenses (incurred in overseas) * Arrange by Asia Assistance Network for body or ashes back to Insured Person s home in Malaysia CANCELLATION DUE TO DELAY * Written Confirmation from Common Carrier / Public Transport stating Period and Reason of Delay / time of mechanical breakdown * Proof of Deposit / charges paid in advance / contracted to be paid for cancelled items * Original scheduled Itinerary and actual boarding pass LOSS OF BAGGAGE AND PERSONAL EFFECTS * Property Irregularity Report / Letter from Common Carrier / Hotel confirming the incident * Police Report stating the circumstances of loss and list of lost items (for baggage and personal effects not checked-in with Common Carrier) * Original Receipt stating the price and year of purchase * Photograph and proof depicting the damages sustained If repair, original repair bill and receipt MISSED DEPARTURE * Written Confirmation from Public Transport (time of mechanical breakdown) / Police Report * Original Invoice and Payment Receipt (additional accommodation/ travel expenses) * Original scheduled Itinerary and actual boarding pass PERSONAL LIABILITY * DO NOT ADMIT LIABILITY WHITOUT ANY PRIOR WRITTEN CONSENT BY ZURICH INSURANCE MALAYSIA BERHAD * Any lawsuit, demand, claim or proceeding of any types relating to the incident of which the claimant becomes aware of, and received from the third party claimant, should be immediately forwarded to Zurich General Insurance Malaysia Berhad Zurich General Insurance Malaysia Berhad ( V) 11th Floor, Menara Zurich, No.12, Jalan Dewan Bahasa, Kuala Lumpur, Malaysia Tel: Fax: Call Centre:

EQ TRAVEL CLAIM FORM

EQ TRAVEL CLAIM FORM Agency Policy No Please note: Sections 1, 2 and 12 must be completed. Sections 3 to 11 complete only the relevant sections. The acceptance of this form is NOT an admission of liability