Travel Claim Form

TO PROTECT YOUR OWN INTEREST, PLEASE COMPLETE THIS FORM YOURSELF

Policy No.

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Insured's First Name

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Insured's Last Name

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Email

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Please enter a valid email address.

Phone

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Fax

Mobile Phone

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Date of Birth

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Address

Passport No.

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Travel Agency

Location

Occupation

Incident Description

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Period Insurance Begin

Period Insurance End

Is there any other insurance in force covering this loss?

If yes, please state insurance company

Type of Policy

Policy No.

Amount of Compensation

Have you or the Claimant had previous claims?

Do you have more than one previous claim?

If yes, please state Date

Circumstances

Insurance Company involved

Amount Claimed

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