VAN AMEYDE UK LTD 34 THE MALL BROMLEY KENT BR1 1TS TEL: +44 (0)208 3150732 FAX: +44 (0)208 3150757 TRAVEL CLAIMS FORM FOR YOUR GUIDANCE ON COMPLETION OF THIS FORM PLEASE QUOTE THIS NUMBER WITH ALL COMMUNICATIONS 1. Before completion please read Page 2, as this details the documentation required to process your claim and reduces the likelihood of further correspondence being necessary. 2. Once Section 1 has been completed proceed to the appropriate section under which you wish to claim and finally, ensure that all claimants sign the declaration on Page 8. 3. A full reply must be given to each question on the claims form which relates to the claim you are making. Ticks, Dashes, N/A, etc. are not acceptable and your form will be returned to be completed fully. 4. Use only BLOCK CAPITALS. 5. If you find there is insufficient room for your answers, please continue on a separate sheet. 6. When completed, please return it to the above address 7. If you do not feel this form adequately covers your claims circumstances, please support with an explanatory covering letter
DOCUMENTS REQUIRED TO SUPPORT CLAIMS IMPORTANT: ORIGINAL DOCUMENTS ARE REQUIRED. WE CANNOT ACCEPT PHOTOCOPIES OR FAXED DOCUMENTS FOR ALL CLAIMS 1. Travel Insurance Certificate, or your Tour Operator's Booking Invoices showing payment of the Insurance premium and total holiday cost and receipt issued by your Travel Agent showing payments, or your schedule of cover confirming your inclusion in your Company Travel Scheme. 2. Travel tickets (Airline, Ferry, Coach, etc.). Unless returned to Tour Operator for refund. 3. Travel Itinerary 4. E ticket booking confirmation email ----------------------.------------------------------------------------------------------------------------------------------------------------------------------------------------------- TRAVEL DELAY 1.Written confirmation from carrier stating all the following: Exact reason for the delay. Original departure time and date. c) Actual departure time and date ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ MISSED DEPARTURE 1. Receipts for additional charges incurred. 2. Written confirmation stating the cause of the claim from the Public Transport Company ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- CANCELLATION/LOSS OF DEPOSIT 1. The Tour Operator's Cancellation Invoice showing charges incurred. 2. Proof of cancellation, e.g. Medical - Medical Certificate to be completed on Page 5. Death - Death Certificate. Also the Medical Certificate is to be completed on Page 5. c) Redundancy - letter from employer confirming date you first were aware of being made redundant and length of service. d) Attendance at Court - the Court Subpoena. ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- MEDICAL EXPENSES/HOSPITAL CONFINEMENT/CURTAILMENT 1. All original receipts for expenses incurred. 2. Additional travel tickets. 3. EHIC if not presented whilst abroad (European travel only). 4. In respect of claims following inpatient hospitalisation abroad, as a result of illness, the Medical Certificate on Page 5 must be completed by your usual UK Doctor. 5. If hospitalised, written confirmation from the hospital concerned of date/time admitted and discharged. 6. Letter from the treating Doctor abroad confirming the medical necessity to return home to the U.K. earlier than planned. 7. The Medical Certificate on Page 5 is also to be completed for claims where curtailment is as a result of illness/death which occurred in the U.K. ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- PERSONAL EFFECTS/MONEY 1. Police Report. 2. Representative s Report. 3. In respect of money claims, currency conversion slips/copy of bank/building society statements or a letter from your bank confirming withdrawal of funds prior to your holiday. 4. In respect of personal effects claims see note on Page 6 - Evidence of OwnershipNalue. 5.Property Irregularity Report, tickets and baggage tags. 6.If claiming for damaged items, estimate of repair. 2
SECTION 1 -------------------------------------------------------------------------------------------------------------------- IMPORTANT: THIS SECTION TO BE COMPLETED BY ALL CLAIMANTS TITLE FULL NAME OCCUPATION DATE OF BIRTH 1.. 2.. 3..... 4.. 5. Address... Post Code. Daytime Tel No : Country of Residence... Email Address:... Country of Destination:... Travel/Tour Operator:... Date Insurance Purchased:... Policy Number/Booking No/Company Scheme Name:... Purpose of trip i.e. Business or Leisure Please state which Departure Date:... Return Date: SECTION 2 TRAVEL DELAY/MISSED DEPARTURE Reason for the Delayed/Missed Departure... TRAVEL DELAY... Schedule Date & Time of Departure...Flight/Ferry No:... Actual Date & Time of Departure...Flight/Ferry No:... No. of Hours Delayed...Airline/Ferry Company:... MISSED DEPARTURE Point of Departure of Trip... Point of Connection Failure... Method of Transport (Air/Coach/Ferry, etc)... Means employed to rejoin holiday/trip...... Amount Claimed... -------------------------------------------------------------------------------------------------------------------- --SECTION 3 CANCELLATION/LOSS OF DEPOSIT Reason for Cancellation... If the Cancellation has been caused by a person not travelling and not insured on your policy, please state relationship of that person to you... Booking Date.. Date Cancelled Total Amount of Deposit Paid.Date Paid. Total Amount of Balance Paid... Date Paid. Amount Refunded....Date Refunded Total amount Claimed If the reason for cancellation is medically related, the medical certificate on Page 5 MUST be completed by the usual Doctor for the person whose condition caused cancellation of the trip. PLEASE ENSURE THAT THE G.P. WHEN COMPLETING THE MEDICAL CERTIFICATE ON PAGE 5, IS AWARE OF THE DATE THAT THE INSURANCE POLICY WAS PURCHASED (QUESTION 11).... 3
SECTION 4 MEDICAL EXPENSES & CURTAILMENT- Date, time and place of Illness/Injury. Illness suffered or injuries sustained...... Details of any previous history... If injury, state circumstances... Did you take an EHIC. Did Was it presented? Did you contact the emergency service as on the policy? Do you hold any private medical insurance, e.g. BUPA, PPP etc? If YES, Policy Number/Scheme Name... Period of extended accommodation ( if applicable ) From.....to... What were your original return travel arrangements?... Were any additional expenses incurred in retuning home If YES, enter reasons and costs below in STATEMENT OF CLAIM. If hospitalised: Date/time admitted...date/time discharged... In case of early return through illness, bereavement or injury please complete the following: Date on which you returned Were you accompanied? If YES, by whom... Reason for the curtailment... Were additional expenses incurred?yes /NO PLEASE ENCLOSE WRITTEN CONFIRMATION FROM THE DOCTOR ABROAD THAT IT WAS MEDICALLY NECESSARY FOR YOU TO CURTAIL YOUR HOLIDAY. STATEMENT OF CLAIM PLEASE LIST EXPENSES BEING CLAIMED AND TREATEMENT RECIEVED CURRENCY PAID AND AMOUNT CLAIMED RECIEPT ATTACHED STATE TO WHOM PAYMENT SHOULD BE MADE..................................... TOTAL CLAIMED 4
MEDICAL CERTIFICATE To be completed in BLOCK CAPITALS by the General Practitioner of the person whose illness/injury give cause for the claim. Any charge made for the completion is the responsibility of the insured and is not refundable under the Insurance Policy. PLEASE ANSWER ALL QUESTIONS. TICKS. DASHES, N/A ETC. WILL NOT BE ACCEPTABLE. 1 Full Name of Patient/Person whose condition has caused the claim 2 Date of birth 3 Are you the regular medical attendant? if so how long? If not, what is your involvement with this matter? 4 Please state precise nature of: Medical condition/illness/injury/cause of death that causes the claim If injury, state how this was caused 5 Please state exact date of onset as in 4 Date first consulted c) Date first diagnosed c) d) Date when there was any serious deterioration, if applicable d) 6Please state, with dates, any incidents relating to the condition as in 4, during the 2 years prior to the date the insurance was effected, to include medication and treatment, tests, specialist referrals or hospitalisation. If no history, state NONE 6Please confirm whether your patient is suffering from or has reviously suffered from any of the following conditions: Heart Related Condition, Hypertension, Diabetes, Arterial Disease Kidney Disease, Malignant Diseases (Cancer), Lung and /or Respiratory Disease (including Asthm or had a Stroke If yes, please provide dates of incidents, to include medication and treatment, tests, specialist referrals or hospitalisation. Continue on a separate sheet if insufficient room 7 Has the person named in 1 above received a terminal prognosis. If yes: on what date was this given to the person named in 1 above the claimant, if not the same person 8 Has the patient ever had a psychiatric or psychological disorder? If yes: state: date of diagnosis treatment received c) dates of in-patient admission/s c) 9 Was the patient waitlisted for hospital admission? If yes: state: date waitlisted date admitted c) for what condition/procedure c) 10 Please state: Whether the patient consulted you prior to their journey as to the advisability of undertaking the holiday or journey. Date If so, on what date Whether, in your opinion the patient was fit to travel at the time of departure 11 Please provide details of state of patient's health at the time the Insurance was purchased 12 If claim is a result if pregnancy, please advise: Date pregnancy confirmed Expected confinement date c) Exact reason for the cancellation c) 13 Please advise the date when it first became apparent that the holiday should be cancelled. 14 Please state the exact date you advised the need to cancel 15 Are you prepared to certify that, solely due to the condition described in 4 above, the claimants are compelled to cancel the travel TO BE COMPLETED BY THE GENERAL PRACTITIONER - I certify that the information given is complete and correct.name ease Name (Please print ).. Address... Qualifications. Signed Date
SECTION 5 PERSONAL EFFECTS/MONEY Date of Loss/Damage/Delay... Time...Place Full details of circumstances............ Was loss/damage reported to the courier? Was loss/damage reported to the airline? Was loss reported to the police? If NO, please state reason why?... Please state the total value of all baggage and personal effects carried on your trip Are the items solely your property? If NO, please specify... Name, Address and Policy Number of household contents Insurers of the address where you reside. Refer to note below, Household Insurers. Policy Number... Insurers Name... Insurers Address... Is there any other relevant policy that may cover your belongings? e.g. Barclaycard, Amex, Jewellery Insurance. If YES, please give details... Have you ever made an insurance claim for personal property or money? If YES, please give precise details... Has a claim been submitted to any other insurer and/or authority in respect of this loss. If YES, please give details...... EVIDENCE OF OWNERSHIP/VALUE Insurers require claims to be supported by evidence of ownership and original purchase price. Please forward original purchase receipts, guarantee cards, instruction manuals, credit card slips/statements or original insurance valuations to confirm ownership of the items being claimed. Replacement estimate/receipts do not prove ownership and are therefore not acceptable. HOUSEHOLD INSURERS Insurers contribute to the settlement of each others claims. This shares costs and helps to keep premiums down. Please give full details of your household contents policy where requested. A contribution made to us should not affect any no claim bonus under your policy. 6
Full description of the articles lost or damaged and the extent of damage where applicable. In respect of delay baggage claims, please list the additional costs incurred Shop/Store and location where purchased Date/year of Purchase 7 Evidence of value Tick where applicable Initial of owner Original price paid TOTAL Amount claimed in sterling OFFICE USE ONLY
SECTION 6 PERSONAL LIABILITY Address of Holiday residence/hotel...... Date, time and place of incident Have you admitted liability? If YES, please explain why... Full details of Circumstances............ Please note any correspondence received from any third party is to be forwarded to us unanswered DECLARATION TO BE COMPLETED BY ALL CLAIMANTS I/We declare that all the information supplied is true and correct in every aspect and that no relevant information has been withheld. On settlement, I/We transfer all rights of subrogation, salvage and recovery to the Insurer and/or their Loss Adjuster. Signed. Date.... Signed.Date... Signed..Date... Signed..Date... Signed Date... DATA PROTECTION ACT 1998 Van Ameyde UK Ltd, will fairly and lawfully collect and record personal information that is supplied within and as a result of this form. We shall share information with your underwriters and their agents and, in certain cases, with other underwriters to help detect and prevent fraudulent claims. We require your consent to process information in this way and by completing and signing this form you are explicitly providing that consent. 8