State Travel Insurance Claim Form by huangyuarong

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									Claim form
                                                                                                    love         your           stuff

Travel Insurance
State, PO Box 298, Shortland Street, Auckland 1140
Level 16, 51 Shortland Street , Auckland, New Zealand
Telephone 0800 155 777, Facsimile (09) 969 6388, Email: claims.travel@iag.co.nz

    WARNING: If you supply any untrue or false information and know that it is not true, IAG NZ Limited shall have the right to refuse your claim.

    Please attach the following:
    1. Any Police or Local Authority or Airline Carrier reports;
    2. For loss of deposits and return travel claims, a copy of your original itinerary is required
    3. Original Doctor’s Certificates or receipts for medical treatment received
    4. Proof of ownership, written repair, replacements, quotes or receipts for personal effects to substantiate your loss
    5. Bank receipts and/or statements are required to substantiate money claims
    6. For rental vehicles, all documents and claim form relating to the accident

    Policy No:                                                                          Period of Cover: From:                          to:

    Mr     Mrs        Ms      Surname:                                                  First Name:

    Date of Birth:

    Postal Address:

    Suburb:                                                                             City:                                                 Post Code:

    Phone Home:                                                                         Phone Work:

    E-mail Address:                                                                     Mobile:

    Did you contact our Emergency Assistance Company for this claim: Yes           No

    Have you made any previous insurance claims? Yes          No

    Are any of the expenses being claimed for, recoverable from either:

    (a) Any Medical Scheme, (b) ACC, (c) Other Insurance Policy, (d) Credit Card or (e) Holiday Package Insurance? Yes           No

    If Yes, state name and address of Scheme or Insurer:


`   Refund Options
    If you would like your refund paid directly to your NZ Bank Account, please tick the relevant box and fill in your details in the
    Express Refund Section.

    Cheque Refund:          Express Refund:    Name of Account:

    Bank Account:
                     Bank         Branch No.          Account No.                          Suffix


`   Claim Details
    Loss Of Deposits, Travel Delay, Early Return, Resumed Travel, Missed Connection, Accommodation and Travel Expenses and Miscellaneous

    Please attach a copy of your original itinerary

    If your journey/holiday has been cancelled, delayed or interrupted, please complete the following as applicable:

    1.   Why was your journey/holiday cancelled, interrupted or delayed?




    2.   Date of Cancellation:

    3.   What costs are you claiming for?

    4.   If the cancellation was due to illness/injury/death to persons other than yourself, please state relationship:

         Where Applicable please attach a Death Certificate to determine the cause of death.


SI6090/3 07/11 Travel insurance Claim form                                                                                                                 1
    Claim form

      5.        Did you hold a return ticket to New Zealand? Yes      No        Please state Total Amount Claimed: $


`     Medical, Dental And Related Expenses
      Please attach original doctor’s certificates or receipts for medical treatment received.

      Name of Person Treated:                                                                                                      Age:

      Date of Treatment/Illness:                                                            Country:

      Please state what you were treated for. If an accident, state what happened:



      Were you suffering from or taking treatment for this illness or injury prior to purchasing your insurance? Yes       No

      If Yes, when and what treatment did you receive?

      Name and Address of your usual Doctor:

                                                                                                 Have you paid
                          Details of Medical/Dental or Related Expenses                                                         Amount        Currency of Amount
                                                                                                 this expense?

           1.                                                                                     Yes   No             $

           2.                                                                                     Yes   No             $

           3.                                                                                     Yes   No             $

           4.                                                                                     Yes   No             $

           5.                                                                                     Yes   No             $

           6.                                                                                     Yes   No             $



`     Baggage, Personal Effects, Money, Emergency Personal Effects And Documents
      Please attach proof of ownership, written repair, replacement quotes or receipts

      1.        Date of Loss/Damage/Theft:                       Time:                      AM     PM         Country loss occurred in:

      2.        Please describe fully how the loss, theft or damage occurred:




      3.        Reported to the Police or Authorities at:                                                                             Date:

      4.        Please advise what action was taken to recover or minimise the loss:




      5.        Have you received any compensation from the Carrier? Yes          No

                If No, state why

      6.        Did the items that were lost or stolen belong to you? Yes       No

                If No, state why

      7.        Are any of the items claimed for insured under any other policy? Yes      No

                If Yes, state the Insurer’s name and address




    SI6090/3 07/11 Travel insurance Claim form                                                                                                                     2
    Claim form

      8.   Have any of these items since been returned to you? Yes        No


                                                                                               Original Date                    Original                 Present Cost
                         Full Description of Property Lost or Damaged
                                                                                                Purchased                    Purchase Price             of Replacement

                                                                                                                         $                          $

                                                                                                                         $                          $

                                                                                                                         $                          $

                                                                                                                         $                          $

                                                                                                                         $                          $

                                                                                                                         $                          $




`     Money
      Please attach proof of ownership eg: bank exchange receipts and police report

      Date of Loss:                          Time:                             AM       PM             Exact Locality:

      Full Circumstances of Claim:

      Full Amount of Loss (please state currency): $


`     Disablement And Death
      Please state details of loss:

      Please state amount claimed: $                                               You may be asked to complete a more detailed claim form for this section


`     Personal Liability
      Details of accident:                                                                                                      Date of accident:

      Please state amount claimed: $                                               You may be asked to complete a more detailed claim form for this section


`     Rental Vehicle Excess
      Please attach all documents and claim form relating to the accident

      Please state amount claimed: $                                               Date of accident:

      Place accident occurred and circumstances of the accident:




`     Declaration: To Be Signed By The Insured Person
      •	   I declare that the particulars stated herein or in any future statement made by me in connection with this claim are true and correct. I further declare that I
           have not withheld, suppressed or concealed any information relevant to this claim.
      •	   I declare that I have no other insurance covering this loss. I further declare that I have not had any previous insurance claims declined relevant to this loss.
      •	   In relation to any claim for injury, illness or death I hereby authorise any doctor, specialist, hospital or any other person or organisation that has treated me,
           to provide IAG New Zealand Limited or its representatives with any and all information with respect to my medical history, consultation, prescription, or
           treatment by them, including copies of all hospital and medical records.
      •	   I consent to IAG New Zealand Limited obtaining from or releasing to appropriate individuals or organisations information relevant to this claim.
      •	   I consent to IAG New Zealand Limited being granted access to all information held about me by the Accident Compensation Corporation (ACC) relevant to
           this claim.
      •	   Your claims history is passed onto, and held by, Insurance Claims Register Ltd (ICR). Participating insurers can access to your claims history on the ICR. I agree
           and consent that IAG New Zealand Limited may give, to, or obtain from ICR information relevant to this claim.



      Insured’s Signature:                                                                                                              Date:
                                      Please type your name if completing electronically
      Have you remembered to include all your receipts and documentation that relate to this claim?
      If yes, please send to: Travel Claims, PO Box 298, Shortland Street, Auckland 1140.


    SI6090/3 07/11 Travel insurance Claim form                                                                                                                                  3

								
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