TRAVEL GUARD INSURANCE CLAIM FORM
1. Issuance of the form is not an admission of liability or a waiver of terms, conditions & exceptions of the insurance contract.
2. No claim under Accident & Illness Section is to be submited without a Doctor's Report as per format (Attending Doctor's Report - Page 3)
3. Please answer all questions completely. In case of insufficient space, please attach an additional sheet.
4. Please submit all Original bills& receipts pertaining to your claim.
Certificate/ Policy No : …………………………… Period From : …………………………… to: …………………………………………………………
DETAILS OF PATIENT/ INSURED PERSON
Name : ………………………………………………………………………………… Phone No: Work :.…… ………………………Mobile…………………………………………
Permanent Address (Turkey) : …………………………………………………………………………………………………………………………………………………………………………………
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Email :…………………………………………………………………………………………
Date of Birth : ....../....../...... Sex: M / F
Assistance Company Ref No.: ………………………………………………………. Passport No.: ………………………………………………………
Date of Departure : ....../......./...... Flight No. …………………… From : …………………………… to: ……………………………
Date of Arrival : ....../....../...... Flight No. …………………… From : …………………………… to: ……………………………
Please indicate whether claim is in respect of: Accident & Illness Travel Delay/Missed Flight Trip Cancellation
Baggage Delay Lost Checked Luggage Emergancy Medical Evacuation Reptriation of Remains
Trip Interruption Injury/ Accidental Death Accident & Permanent Disability Accident & Denta
Prescribed Medicine Recuperation at Hotel Legal Fees Bail Bond Assurance
Please complete the Section relevant to your claim.
LOSS/DELAY OF CHECKED BAGGAGE
Describe when & where the loss/delay took place: ……………………………………………………………………………………………………………………………………………………
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State the extent of Loss: ……
Name the common carrier:………………………………………………………………………………………………………………………………………………………………………………………
Flight No.: …………………… From : …………………………… to: ……………………………
Flight No. …………………… From : …………………………… to: ……………………………
Was the common carrier notified at the time of loss? Yes No Airline Reference No. ……………………………….
Details of compensation received from carrier: …………………………………………………………………………………………………………………………..
Scheduled date/time of Arrival: ....../....../...... ...... :...... hrs. Actual date/time when luggage delivered :....../....../...... ......:.... hrs
age
Item Purchased/Lost * Date of Purchase Place Cost
TOTAL
Less Compensation received from Airline:
Net Amount:
* In case of Delay, please provide details of purchases made
* In case of Loss, please provide details of items lost.
TRAVEL - DELAY/MISSED/CANCELLATION/INTERRUPTION
Flight No. …………………………… Date ....../....../...... From : ……………………………………………… to: …………………………………………………………
Scheduled time of Departure: …………………………… Actual time of Departure: …………………………… No. of Hours delayed:……………………………
Whether accomodation & board provided by carrier: Yes No
Details of Expense incurred Date Place Amount
TOTAL
MEDICAL ACCIDENT & ILLNESS/DENTAL/ PERMANENT DISABILITY BENEFIT/EMERGENCY MEDICAL EVACUATION/
PRESCRIBED MEDICINE/RECUPERATION AT HOTEL
In event accident, details of accident i.e. how, when, where it took place: ……………………………………………………………………………………………………………………
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Date: ……………………………………………………………………… Place: …………………………………………………………………………………………………………………………
In event of illness, state nature and diagnosis, and advise when & where symptoms first occurred: ………………………………………………………………………………
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Date: ……………………………………………………………………… Place: …………………………………………………………………………………………………………………………
Name & Address of consulting physician: ………………………………………………………………………………………………………………………………………………………………
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Have you ever been treated for this illness before: Yes No
If yes, provide name & address of physician: …………………………………………………………………………………………………………………………………………
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Provide name & address of your family physician: ……………………………………………………………………………………………………………………………………………………
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Provide name of any prescription medicine you are presently taking :……………………………………………………………………………………………………………………………
Indicate other health insurance coverage, including name, address, policy number & certificate number of insurer:
……………………………………………………………………………………………………………………………………………………………………………………………………………………………
DETAILS OF MEDICAL EXPENSES
Details of treatment In/ Out Patient Charges (Currency) Status of Payment
From To Eg : USD / EURO Paid/ Outstanding
Paid
Outstanding
'TOTAL
Was Assistance Co. contacted: Yes No. If Yes, Reference No.
If No, give reasons: …………………………………………………………………………………………………………………………………………………………………………………………………
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AUTHORIZATION
I hereby authorize any hospital, physician, or other person who has attended or examined me, to furnish the insurance company,
or its authorized representative, any and all information regarding any illness or injury, medical history, consultation,
prescriptions or treatment and copies of all hospital or medical records pertinent to this claim, a photostat copy of this authorization shall be
deemed as effective and as valid as the original.
Date: Place:
Signature of insured :_________________________________________________
Attending Doctor's Report
Patient's Name: ……………………………………………………………………………………………………………… Age: …………… Sex: M/F
Address: ………………………………………………………………………………………………………………………………………………………………………………………………………………
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Date contacted: ………………………………………………………………………………………… Time: …………………………………………………………………………………………………
For Accidental Injury/Permanent Disability
Nature of Injury: ……………………………………………………………………………………………………………………………………………………………………………………………………
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X-Ray Taken: Yes No Date taken: ………………………………………………………………………………………
Diagnosis and Treatment Given: ………………………………………………………………………………………………………………………………………………………………………………
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Describe any other disease or infirmity affecting present condition: ………………………………………………………………………………………………………………………………
For Sickness/Emergency Medical Evacuation/Recuperation At Hotel/Prescription Medicine Replacement /Dental Examination
Nature of Illness: ……………………………………………………………………………………………………………………………………………………………………………………………………
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Diagnosis and Treatment Given: ………………………………………………………………………………………………………………………………………………………………………………
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When did patient's symptoms first appear: …………………………………………………………………………………………………………………………………………………………………
Describe any other disease or infirmity affecting present condition: ………………………………………………………………………………………………………………………………
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Is condition due to Pregnancy: Yes No Is illness due to any pre-existing condition: Yes No
Signature:_________________________________________________
Attending Doctor's Signature
ACCIDENTAL DEATH/REPATRIATION OF REMAINS
In the event of an accident, details of accident i.e. how, when, where it took place: ………………………………………………………………………………………………………
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Date: ……………………………………………………………………… Place: …………………………………………………………………………………………………………………………
In the event of illness, state nature and diagnosis, and advise when & where symptoms first occurred: …………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………………
Date: ……………………………………………………………………… Place: …………………………………………………………………………………………………………………………
Name & Address of consulting physician: ………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………………
Have you ever been treated for this illness before: Yes No
If yes, provide name & address of physician: …………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………………………………………………………………
Provide name & address of your family physician: ……………………………………………………………………………………………………………………………………………………
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Provide name of any prescription medicine you are presently taking :……………………………………………………………………………………………………………………………
Indicate other health insurance coverages, including name, address, policy number & certificate number of insurer:
……………………………………………………………………………………………………………………………………………………………………………………………………………………………
LEGAL FEES/ BAIL BOND ASSURANCE
Describe incident: ……………………………………………………………………………………………………………………………………………………
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State of the incident: ………… ………………………………………………………………………………………………………………………………………………………………………………………
Name of the eye witness :………………………………………………………………………………………………………………………………………………………………………………………
Eye witness' Phone Numbers………………………………………………………………………………………………………………………………………………………………
Lawsuit filed?: Yes No [ Please forward a copy of the suit (police report, public prosecutor report, eye witness report,etc.) ]
Have you contacted an attorney ? If so, provide name, full adress, phone numbers ….................……………………………………………
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