Claim Form Travel Medical

							                                                         Comcover Member Services
                                                         Official Travel Overseas – Medical Claim Report


Section A         Member Agency Name
Member
Agency
                  Details of person within member agency to contact concerning the claim:
Details
                  Name
                  Business Address
                  Telephone                                                         Fax
                  Email
                  Date that you or the organisation first became aware of the claim     /                  /
                  Does this claim arise out of travel that was approved?                      Yes         No

Section B        Name of Traveller
Traveller
                 Occupation
Details
                 Employer
                 Date of Birth                                /     /
                 Business Address
                 Telephone                                                                   Fax
                 Email



Section C        Did the incident occur whilst on
                                                        Yes                No
Travel Details   Official Travel?
                 Details of Official Travel:
                 Travel commencement date                     /    /             Travel finishing date           /     /
                 Details of approved leave while travelling:
                 Leave commencement date                      /    /             Leave finish date               /     /
                 Destination



Section D        Have you lodged a claim with
                                                        Yes                     No
Comcare          Comcare in the first instance?
Declaration      Date Comcare notified                        /     /
                 Has your claim been rejected by
                                                        Yes                     No
                 Comcare?
                 Reason for rejection



Section E          For Illness details please go to Section F
Accident
Details            Date of accident                           /     /
                   Type of injury


                   Full details of accident


                   Date of first medical consultation         /     /

                   Name of doctor and/or hospital

                   Details of other treatment by
                   doctor and/or hospital




  Comcover Member Services                                                                           Email claims@comcover.com.au
  Locked Bag 4830                                                                                                 Fax (03) 9297 9375
  Melbourne VIC 3001                                               1                                          Toll Free 1800 651 540
                                                            Comcover Member Services
                                                            Official Travel Overseas – Medical Claim Report


                     Date and time admitted into
                                                                 /       /                         Time
                     hospital
                     Date and time discharged from
                                                                 /       /                         Time
                     hospital



Section F            Date of commencement of illness              /         /
Illness Details
                     Type of illness

                     Date of first medical consultation           /         /
                     Name of doctor and/or hospital

                     Details of other treatment by
                     doctor and/or hospital

                     Date and time admitted into
                                                                  /         /                       Time
                     hospital
                     Date and time discharged from
                                                                  /         /                       Time
                     hospital
                     Was any treatment for the illness
                     received within 30 days prior to      Yes                                      No
                     departure?



                       Attachments

                                Proof of cause i.e. original doctor’s/hospital’s certificate relating to injured or ill person.


                       Failure to provide these items may result in delays in processing your claim.




        ___________________________________           _______________________________________                     _________________
           Name of person reporting the claim             Signature of person reporting the claim                        Date




        ___________________________________           _______________________________________                     _________________
        Name of Agency Insurance Contact Officer       Signature of Agency Insurance Contact Officer                     Date




  Comcover Member Services                                                                                Email claims@comcover.com.au
  Locked Bag 4830                                                                                                      Fax (03) 9297 9375
  Melbourne VIC 3001                                                    2                                          Toll Free 1800 651 540