Travel delay, abandonment & missed departure claim form Vhi Travel Claims, Claim Ref Number Intana, Collinson Insurance Services Ltd., IDA Business Park, Athlumney, Navan, Co. Meath, Ireland Email: vhitravelclaims@intana-assist.com Tel: 046 9077358 Important Information Original documents need to be supplied. We recommend that you retain copies of all documentation forwarded to us. Please ensure that all questions are completed in full in BLOCK CAPITALS. Note: If the information and documentation required is not provided your claim will not be processed. If you are unable to provide the documentation required, you need to provide a written explanation. The following documentation is required as part of your claim. Please insert to indicate that documentation has been included. Completed claim form Booking details Report from the carrier If the claim is a result of a car breakdown Additional expenses Fully complete each section that is relevant to your claim and ensure you have signed the claim form. A booking invoice confirms the full costs, deposits paid and date of booking. Written report from the carrier confirming the delay, detailing the reason for the delay and providing information regarding any arrangements made by the carrier, including the time of the next available flight / seacrossing etc. Provide garage report detailing breakdown assistance provided. If assistance was not provided by a garage please provide garage report showing subsequent repairs completed after the event Receipts for additional expenses incurred following missed departure. 01022018 Page 1 of 7
Section 1: Personal details Title Mr/Mrs/Ms/Miss/Other First Name Surname E-mail address Date of Birth DD/MM/YY Full address Postcode Contact number (daytime) Contact number (evening) Occupation Policy number Policy issue date DD/MM/YY Date trip was booked Departure date DD/MM/YY Return date DD/MM/YY Country of destination Name & contact details of travel agent / tour operator Purpose of Trip Business Pleasure 01022018 Page 2 of 7
Section 2: Details of other insurers This information is needed as some bank and credit card accounts have travel insurance entitlements. If you paid for your trip by credit card please provide your card type and issuing bank Credit card type Issuing bank If you have a bank / building society current account please provide the name of the financial institution, the account type and the account details Name of bank / building society Account type Standard / Gold / Platinum BIC IBAN number If you or any of the insured party have any other travel insurance that may cover you for this claim please provide the relevant details Name of company Policy number 01022018 Page 3 of 7
Section 3: Settlement details By entering your bank account details, you confirm that Intana has your full authority to remit monies directly to that account by the BACS or other electronic banking system. You also accept that, providing payment is remitted to the bank account designated by you, Intana shall have no further liability or responsibility in respect of such payment, and that it shall be your sole responsibility to make collection of any misdirected payment. Name of account holder Type of current account (e.g. Platinum, Gold, Standard) Name & address of bank / building society BIC IBAN number (This number appears on the top right hand corner of your bank statement) 01022018 Page 4 of 7
Section 4: General travel information If destination changed because of delay, please give details. Original airline / ferry operator / similar From To Flight number Departure date Departure time Actual airline / ferry operator / similar From To Flight number Departure date Departure time If your journey consisted of more than one flight, please list all flight routes and numbers Names of people claiming who are insured under this policy If you were refunded for any unused element of your ticket please indicate the amount refunded 01022018 Page 5 of 7
Please complete the relevant section below Section 5 to be completed for Travel delay Section 6 to be completed for Trip abandonment Section 7 to be completed for Missed departure Section 5: Travel delay section Please state the reason for the delay and enclose the written report from the carrier involved (Please note that failure to provide the above documentation may delay your claim) If your claim is as a result of strike action please give the name of the company / organisation causing the delay Section 6: Trip abandonment section How long were you delayed before you decided to abandon your trip? What alternative were you offered by your tour Operator / airline / ferry company? What was the cost of your trip? Amount of refund made by travel Company Section 7: Missed departure section Amount claimed Time of departure What caused your delay? Please tick as appropriate Time you left home Delay to scheduled public transport (please enclose written confirmation of the delay from the service provider) Breakdown of the car in which you were travelling (please enclose garage report) Accident involving the car in which you were travelling (please enclose the accident report including third party details) 01022018 Page 6 of 7
Section 8: Personal Declaration Data Protection Statement In order to adjudicate on your claim, Vhi and Intana will process the personal data you have provided on this form, together with any personal data that you have authorised third parties to provide to us. Certain processing of your personal data is required in order for us adjudicate on your claim and for us to be able to operate the business of providing travel insurance policies. Vhi Healthcare DAC of Vhi House, Lower Abbey Street, Dublin 1 ( Vhi ), and Collinson Insurance Services Limited trading as Intana, of IDA Business Park, Athlumney, Navan, County Meath ( Intana ), and Great Lakes Insurance, SE of Plantation Place, 30 Fenchurch Street, London, EC3M 3AJ ( the Insurer ), are the companies that control and are responsible for processing the personal data in relation to your claim. We will process your personal data in accordance with the Vhi Data Protection Statement which has previously been provided to you. If you would like another copy of the Vhi Data Protection Statement it is available at Vhi.ie, or you can request a copy by calling us on (056) 444 4444 or 1890 44 44 44. Obtaining Additional Information In order to process and to establish the eligibility and appropriateness of your claim we will, as appropriate; Contact the facility and your treating practitioners (including, where relevant, your GP) on your behalf to request a copy of all necessary information including, if requested, copies of the facility/medical records relating to the treatment and/or services received by you as part of this claim. Approach any third party who holds information relating to the incident giving rise to this claim and obtain from them such information as is required to assist in the investigation and resolution of this claim. Share information with other insurers or financial institutions for the purposes of dealing with this claim and eliminating insurance fraud Please deal solely with myself in respect of this claim Or Authorisation for Broker/Other Third Party - optional: I hereby authorise (name of broker or other third party) to handle this claim on My/Our behalf and agree that all communications in respect of the claim will be solely through them. Declaration I declare that the information completed above at the time of signing this declaration is true in every respect. I authorise Intana on behalf of the Insurer to pay the appropriate benefits, for services provided, to the treatment facility and medical practitioners concerned. I understand that the details of these amounts will be included in my settlement statement and I will contact Intana directly with any queries. Charges which are not eligible for benefit will remain my responsibility to settle directly with the treatment facility/medical practitioner concerned. Important you must sign here: Patient s (or Parent/Legal Guardian if patient is under 18 years)* Signature Date *For claims in relation to a dependant under 18 years at the time of signing this form, please note that all correspondence and relevant payments will be made to the policyholder. Please check that you have entered your Policy Number. Please note that the address you provide is purely for data validation purposes. If you need to update your contact details or membership/personal data, please contact our Customer Services Helpline at (056) 444 4444 or 1890 44 44 44. Vhi Healthcare DAC trading as Vhi Healthcare is regulated by the Central Bank of Ireland. Vhi Healthcare is tied to Collinson Insurance Services Limited for MultiTrip Travel Insurance, which is underwritten by Great Lakes Insurance SE, UK Branch. Check List If all requested information is not supplied we will not be able to process your claim. Before submitting your claim please ensure: All relevant documentation outlined on page 1 has been submitted with this claim. All supporting documentation are originals (we recommend that you retain copies). This claim form has been fully completed and signed. Please return your completed form and supporting documentation to: Vhi Travel Claims, Intana, Collinson Insurance Services Ltd, IDA Business Park, Athlumney, Navan, Co. Meath, Ireland Vhi Healthcare DAC trading as Vhi Healthcare is regulated by the Central Bank of Ireland. Vhi Healthcare is tied to Collinson Insurance Services Limited for MultiTrip Travel Insurance, which is underwritten by Great Lakes Insurance SE, UK Branch. 01022018 Page 7 of 7