Travel Insurance claim AXA Assistance Service Airsavings PO Box Swords

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Travel Insurance claim AXA Assistance Service Airsavings PO Box Swords Powered By Docstoc
					Travel Insurance claim                                                                                   AXA Assistance Service Airsavings, PO Box 10400,
                                                                                                                               Swords, Co. Dublin, Ireland

Please answer all the questions contained in this claim form, leaving items blank, using ticks, dashes and N/A may make it necessary for us to return your
                          claim forms or lead to us asking unnecessary questions thus delaying the processing of your claim.
        NOTICE: WE WILL NEED YOUR INTERNATIONAL BANK ACCOUNT DETAILS (IBAN AND SWIFT CODES INCLUDED) AS ANY REIMBURSEMENT WILL BE PAID BY
                                                        INTERNATIONAL BANKING TRANSFER.
                                                                      Personal details - Required for all claims

 Claimant       Mr/Mrs/Miss/Ms                                                                        Home Address
 Details
                Surname
                Forenames
                Date of birth                                                                         Postcode
                National Ins No.                                                                      Tél. personnel                              Work tel.

                Nationality                                                                           E-mail
                IBAN
                SWIFT (BIC)
                Account Holder


                                   Policy and travel details                                                                Type and amount of claim
                                                                                                               Policy Benefit                                 £'s / €'s Claimed
 Policy number
                                                                                                       Medical Expenses abroad
 Date issued
                                                                                                            Hospital Expenses
 Departure date                                                                                          Convalescence Benefit
 Return Date                                                                                                    Cancellation

 No. In party
                                                                                                               Baggage Delay
                                                                                                   Loss/Damage/Theft of baggage
 Destination(s)
                                                                                                               Legal Expenses
                                 Important Note: Some of the benefits detailed may not be available upon the policy you hold.


   It is against the law to submit a fraudulent insurance claim. If your claim is found to be fraudulent your claim will be declined and the
                                                             authorities informed.
1. I/We hereby declare that all information, answers, and documents given in connection with this claim are true and correct to the best of my/our knowledge and belief. I/We
have not omitted any material information, which would effect the Underwriters judgment of the claim. I confirm that where a claim or claims are made on behalf of others, I have their full
authority to act on their behalf, and I confirm that I understand that neither AXA Assistance Claims Centre Services nor the underwriters will accept responsibility if any payments are not
distributed proportionately to the persons concerned.
2. I/We understand that the information on this form will be passed to or used by AXA Assistance Claims Centre Services for my insurance, this includes underwriting,
processing, handling claims and preventing fraud and could include passing details to agents or other Insurers.

3. I/We give my/our authority to AXA Assistance Claims Centre Services to contact my household insurers or medical insurers or other travel insurers regarding a contribution.


                       I have read and fully understand the declarations above (ALL persons claiming must sign)
                Claimants Name                              Claimants Signature                                    D.O.B.                                            Dated
Cancellation - page 1
Reason for cancellation - Please tick ONE box only
Non medical                           Illness                              Injury                           Death
Documents you need to send us - SEND ORIGINAL DOCUMENTS BUT PLEASE KEEP COPIES FOR YOUR RECORDS
1. Insurance policy and flight booking invoices.                                          certificate. In addition if the deceased was insured under the Certificate of Insurance upon
2. If cancellation is due to redundancy we require a letter from your former              which this claim has been submitted we require a copy of the Grant of Probate issued in
employer which confirms that you have been made redundant and are due to receive a        respect of the deceased's estate.
payment under current Redundancy Payment Legislation, the position you held and your      5. If this claim is being submitted as a result of an injury please provide a full
length of service.                                                                        description of the incident leading to the injury. If a third party was involved please provide
3. If cancellation is on medical grounds, including death, the attached medical           their details and those of their insurer if available.
certificate must be completed by the usual medical practitioner of the individual whose   6. If cancellation is for a reason other than those detailed in points 3, 4 and 5,
condition has led to the submission of the claim.                                         please forward independent written evidence of the incident or circumstances that have
4. If cancellation is due to a death we require a certified copy of the death             resulted in the submission of a claim.


                  Please provide a written explanation as to why if you are unable to supply any of the documentation requested.

                                                   Please answer ALL questions below - BLOCK CAPITALS PLEASE
1. Date and time you became aware of the need to cancel your holiday:                                                                 /         /
2. If cancellation was due to a person not booked to travel please state their name and relationship to you.
Name                                                                                         Relationship


3. Total amount claimed

4. Names and D.O.B. of all those cancelling.

                                           Name                                                                                       DOB




5. Please detail the reasons for cancellation below (continue on a separate sheet if necessary)
Cancellation - page 2
7. Other Insurance
    a. Are the expenses you claim insured by any other policy you have e.g. Annual/Credit Card Policy? N.B. : A contribution payment is normal practice where 2 policies cover the
       same loss.

            YES                 NO
    b. If yes, please supply the following details :

Company Name
Company Address
Policy No

8. Previous claims
    a. Have you made any previous travel insurance claims?                                               YES              NO
    b. If yes, please give details :




9. Health conditions
At the date of arranging your trip were you, any close relative, any member of your party or anyone on whom your trip depended:

     a. Aware of any medical condition(s) or set of circumstances that could reasonably be expected to give rise to a claim?          YES              NO
     b. Did you, any close relative, or any other person upon whom your travel plans depended (including non family
        companions) have :
    i) an ongoing medical condition (or any medical complication directly attributable to that condition) investigated by a
    registered medical practitioner within the last 12 months?
                                                                                                                                      YES              NO
     ii) a medical condition for which there had been prescribed medication or treatment other than a minor ailment by a
     registered medical practitioner during 90 days immediately preceding the period of insurance?
                                                                                                                                      YES              NO
     iii) hospitalised within the last 12 months or on a waiting list for an operation, consultation or investigation?                YES              NO
     iv) expected to give birth before or within 8 weeks of the date of arrival home?                                                 YES              NO
     v) been travelling against the advice of a medical practitioner, or travelling for the purpose of obtaining medical treatment?   YES              NO
     vi) been given a terminal prognosis ?                                                                                            YES              NO
     Did you obtain a letter concerning any of the above from your doctor? If yes, please forward a copy of the letter.               YES              NO
If you answered yes to any of the above please give further details of the condition or circumstance:
Medical Certificate
This certificate is to be completed by the Registered Medical Practitioner of the person whose illness/injury has given rise to the claim.
Please note !
     - Any charge made for the completion of this Medical Certificate 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.
    - This information will be treated as Private and Confidential.
    - A certificate not containing the specific information requested will not normally suffice.

1. Full name of persons whose condition has given rise to the claim :

2. DOB :                      /        /
3. Are you the registered medical practitioner of the person named in point 1?                 YES                  NO
(a) If yes, for how long ?

(b) If no, what is your involvement with this matter?

4. State precise nature of : Medical condition/illness/injury/cause of
death, that gives rise to the claim.

If injury or death caused by injury, state how this was caused


5. Has the patient suffered from the same or a similar condition in the past?                  YES                 NO
6. (a) State exact date of onset as in point 4.                     /        /
      (b) Date first consulted.                                     /        /
      (c) Date of any serious deterioration, if applicable.         /        /
       Please provide details of any medical conditions
       including those which are considered to be
       pre-existing or on-going which have been
       investigated or treated, for which medication has
       been prescribed, consultant or hospital referrals
       made, or in-patient treatment received, within the
       last 24 months. Please also include details of any
       conditions for which treatment has been refused.

7. Has the person been on sick leave and for how long?                     YES                NO
8. Has the person named in 1 above received a terminal prognosis?
                                                                                          YES                  NO
If yes, what date was the terminal prognosis given to:
(a) the person named in 1 above                                    /        /
(b) the claimant, if not the same person.                          /        /
9. If claim is a result of pregnancy, please advise:

 (a) Date pregnancy confirmed              /      /           (b) LMP.           /       /             (c) ECD.         /   /
 10. (a) Did the person named in 1, if travelling, consult you prior to their journey
 as to the advisability of undertaking the holiday or journey. If yes, on what date.     YES                  NO                /   /
(b) If travelling, in your opinion was the person named in 1 fit to travel at the date of departure?         YES            NO
11. Are you prepared to certify that, solely due to the condition described in 4 above, the
claimants are compelled to cancel their travel arrangements?                                                 YES            NO
To be completed by the Registered Medical Practitioner
I have examined the person named in 1 and/or referred to his/her medical records and I declare that the information given is correct and that no details relevant to the case have been
omitted.
Name (Please print)                                                                                        Qualifications



Address                                                                                                    Surgery Stamp.



Signature                                                                                                  Date
Overseas medical costs - page 1
Prior to any expense, you should imperatively call the AXA Assistance platform (see phone number given in your confirmation email) to get an agreement
for costs reimbursement.
                       Documents you need to send us - SEND ORIGINAL DOCUMENTS BUT PLEASE KEEP COPIES FOR YOUR RECORDS
1. Insurance policy invoice.                                                                    Administration. If the insured passed away due to illness rather than as a result of injury, the
2. Boarding card.                                                                               attached medical certificate must be completed by the deceased's usual medical practitioner.
3. Original receipts for all expenses incurred, please number the receipts and put the number
in the column headed " Receipt No. " when completing Question 7.                                6. Any proof of reimbursement of any insurance companies.
4. If you answered " yes " to question 4, detailed below, you must have your doctor complete    7. Any proof document showing which expenses are still under your financial responsibility.
the attached medical certificate.                                                               8. Any written document by the other insurer(s) or credit card company stating that they
5. If this claim is being submitted on behalf of the estate of a deceased insured we require    refused to cover expenses.
certified copies of the death certificate and the Grant of Probate/ Letters of

                          Please provide a written explanation as to why if you are unable to supply any of the documentation requested.

                                                      Please answer ALL questions below - BLOCK CAPITALS PLEASE

1. Date and time illness or injury occurred.                                                    5. Hospital/Clinic details.
     /        /                                                                                 Treating Doctor
2. Country and town where illness or injury occurred.                                           Address



3. Description of illness or injury.
                                                                                                Tel./ Fax
                                                                                                Treating Doctor
                                                                                                6. If you were an inpatient please complete the following.:
                                                                                                (a) Date of admittance and
                                                                                                discharge                             /         /                   /         /
4. Previous medical history                                                                     (b) Did you contact AXA
                                                                                                Assistance ?                                 YES                  NO
Have you previously suffered from the condition that has resulted in the submission of this
claim, or nay related condition ? Please tick.                                                  (c) If yes, please complete (d) and (e), if no, please provide a written explanation as to why
                                                                                                AXA Assistance was not contacted.
  YES                 NO                                                                        (d) Date of first call                /         /
                                                                                                (e) Reference No.

7. Medical expenses (continue on separate sheet if necessary)
  Receipt No.               Date          Description of item       Bill from            Currency               Amount              Exch rate            Paid Y/N          Office use only
Overseas Medical Costs - page 2
8a. Do you hold any private health care (e.g. BUPA, PPP), personal accident
insurance or other travel insurance (insurance included in your credit card)?                                     YES             NO
8b. If yes, please provide details below and attach a copy of the policy schedule

Policy No.                                                                                           Address of Insurance Company

Renewal date

Insurance Company

9. Did you obtain an E111 Department of Health form(s) for your trip?                                            YES              NO
Have you made a claim under the E111 and have you received reimbursement ?                                       YES              NO
If yes, how much have you been reimbursed? (Please attach evidence of this.)

10. Previous claims
a. Have you made any previous claims for medical expenses incurred overseas ?                                     YES             NO
b. If yes, please give details below :




11. Health conditions
At the date of arranging your trip were you, any close relative, any member of your party or anyone on whom your trip depended:

         A. Aware of any medical condition(s) or set of circumstances that could reasonably be expected to give rise to a claim ?                             YES                 NO
         B. Did you, any close relative, or any other person upon whom your travel plans depended (including non family companions) have :
         i) an ongoing medical condition (or any medical complication directly attributable to that condition) investigated by a registered medical
         practitioner within the last 12 months?                                                                                                              YES                 NO
         ii) a medical condition for which there had been prescribed medication or treatment other than a minor ailment by a registered medical
         practitioner during 90 days immediately preceding the period of insurance?                                                                           YES                 NO
         iii) hospitalised within the last 12 months or on a waiting list for an operation, consultation or investigation?                                    YES                 NO
         iv) expected to give birth before or within 8 weeks of the date of arrival home?                                                                     YES                 NO
         v) been travelling against the advice of a medical practitioner, or travelling for the purpose of obtaining medical treatment?                       YES                 NO
         vi) been given a terminal prognosis ?                                                                                                                 YES                NO
         Did you obtain a letter concerning any of the above from your doctor? If yes, please forward a copy of the letter.                                    YES                NO
If you answered yes to any of the above please give further details of the condition or circumstance:




12. Are you expecting to receive or are you going to submit any further accounts?                                  YES               NO
If yes, please provide details on a separate sheet.

Important Notes
i) Any excess deduction applicable to each claim as stated in the Policy Terms and Conditions must be paid before expenses detailed in question 7 can be settled. If this was paid to the
Hospital or Doctor Overseas, please enclose the receipt. Otherwise a remittance payable to AXA Assistance Deutschland GmbH for the amount of the excess should be forwarded with
this form.
ii) Payment of admissible expenses would normally be made in favour of the claimant. If you require payment to be made in favour of somebody else please forward their details.
Baggage Delay/Loss/Damage/Theft - page 1
                       Documents you need to send us - SEND ORIGINAL DOCUMENTS BUT PLEASE KEEP COPIES FOR YOUR RECORDS
1. Insurance policy invoice.                                                                     5. Damage claims only - please provide an estimate for repair or if the item is damaged
                                                                                                 beyond repair we require written confirmation of this from a relevant tradesman, please retain
2. Boarding card.
                                                                                                 all damaged items as we may require them to be forwarded to our offices.
3. If your claim is for property lost or damaged whilst in the custody of the airline company    6. Baggage delay claims only - receipts for necessary purchases of clothing and toiletries
please forward a copy of their or their agents report, their written confirmation that no        and the airline company confirmation of the incident and the date and time your luggage
payment has been issued to you and your boarding card and baggage tags.                          arrived.
4. For all personal possessions, valuable and precious objects claimed please provide
pre-loss supporting documentation in the form of receipts or visa/bank statements showing        Important - please number all receipts for expenses incurred or pre-loss
the purchase of the items claimed for. Please also forward the manuals and guarantee             supporting documentation and put the number in the column headed " Ref
documentation for any watches, cameras or electronic goods claimed for.                          No " when detailing the expenses or items for which your claiming on page
                                                                                                 2.
                           Please provide a written explanation as to why if you are unable to supply any of the documentation requested.

                                                       Please answer ALL questions below - BLOCK CAPITALS PLEASE
1. Where and when did the loss, theft or damage occur?                                          2. Baggage delay claims only.
Date and time the loss, theft or damage was discovered.                                         (a) Date and time of your arrival in
                                                                                                resort.                                         /       /
      /            /                                                                            (b) Date and time your received your
                                                                                                                                                /       /
                                                                                                luggage.
Place of incident (country and resort or town)
                                                                                                (c) Length of delay.

                                                                                                (d) Compensation received from the airline company, please provide documentary evidence
                                                                                                of this. If no compensation received please state.
3. Was the incident reported to the:

                               Date                   Time                 Reference

          Police                                                                                (e) Flight number
   Carrier (airline
    company)
4. Detail below the circumstances surrounding the incident and the precautions taken to protect your property, continue on a separate sheet if necessary.




5. Where were the items at the time of the loss, theft or damage ?


6. Loss and theft claims only - what actions did you take to attempt recover your property?




7. Other Insurance
a. Details of your Household Insurance

Insurer Name                                                                                    Policy No. :

Insurer Address                                                                                 Details of any previous household or travel insurance claims.




Post Code

b. Has a claim been submitted with any other insurer e.g. your household insurer or to the airline company ?           YES              NO
If yes, give details and a claim reference number below:
Baggage Delay/Loss/Damage/Theft - page 2
IMPORTANT NOTE : THIS POLICY IS AN INDEMNITY POLICY WHICH WILL RESTORE THE SITUATION TO WHAT IT WAS AT THE TIME OF LOSS : THE
VALUE OF ITEMS CLAIMED FOR IS CALCULATED, NOT AT REPLACEMENT AS NEW VALUES, BUT AT WORTH AT THE TIME OF LOSS, TAKING AGE AND
DEPRECIATION INTO ACCOUNT, I.E. SECONDHAND REPLACEMENT COST.

                                Please complete the sections below that are relevant to your claim - BLOCK CAPITALS PLEASE
Details of damaged, stolen, destroyed or lost Personal Baggage (continue on a separate sheet if necessary)
Please provide full details of each item claimed for. (For cameras give make and model number, lens details etc. for watches give make, model, nature and quality of
metal from which the case was made, type of strap, number of jewels etc. For jewellery give nature and quality of the metal content, size and type of stones etc.).
Purchase receipts and valuations must be provided.
     Ref No.      Description of item       Owner         Place of Purchase   Date acquired   Purchase method   Purchase cost      Replacement cost     Office use only




Details of damaged, stolen, destroyed or lost Personal Baggage (continue on a separate sheet if necessary)
        Ref No.             Claimant name           Description of item           Date                  Cost                    Currency              Office use only
 Legal Expenses
                                                          Legal Expenses Claims
Prior to any expense, you should imperatively call the AXA Assistance platform (see phone number given in your confirmation email) to get
                                                 an agreement for costs reimbursement.
                      Documents you need to send us - SEND ORIGINAL DOCUMENTS BUT PLEASE KEEP COPIES FOR YOUR RECORDS
1. Insurance policy and flight booking invoices.                                       4. Please provide the details of your registered medical practitioner and any
                                                                                       specialists from whom you have received treatment and your written confirmation
2. Your boarding card.
                                                                                       that we may contact them for further information.
3. Send us a fully detailed account of the incident giving rise to the claim including 5. Send us ALL correspondence received from any third party - THIS MUST BE
addresses of any witnesses or third parties involved.                                  UNANSWERED.
 Special Note - The Underwriters will decide whether legal proceedings are to be commenced, if you instruct your own solicitor the Underwriters WILL NOT
                                     accept liability for any fees incurred prior to a claim being accepted under the insurance.

                                           Give details of your claim below (continue on a separate sheet if necessary)