Insurance Brokers and Risk Managers Please return completed form

Insurance Brokers and Risk Managers Please return completed form to: GPO Box 3245 Brisbane Q 4001 or Fax 07 3839 5344 For TRAVEL Claims: > For baggage lost/stolen/damaged advise the airline/hotel/motel/local police or any other authority and obtain a written report from them of your potential claim. Obtain two quotes for repair/replacement. > For medical expenses retain medical invoices/receipts/reports to attach with completed claim form. If you have private health insurance please submit a claim to the provider first. > For loss of pre-paid travel arrangements retain medical invoices/receipts/ reports/ticket stubs to attach with claim form. > For liability claims – do not admit liability, advise our office of any incident that may develop into a claim against you as soon as possible and retain all copies of any written demands you receive. Insurance Brokers and Risk Managers Level 3 82 Eagle Street Brisbane Q 4000 GPO Box 3245 Brisbane Q 4001 Phone 07 3832 6727 Fax 07 3839 5344 TRAVEL INSURANCE CLAIM FORM Insured Name Mailing Address Telephone No. Business Home Note: If you do not give us your ABN we may have to withhold tax on any monies paid for your claim. Email Address • Do you claim an input tax credit on your insurance premium? YES NO • If YES your input tax credit entitlement % is • Your ABN is Insurance Company • Date holiday deposit paid Policy Number / / CIRCUMSTANCES OF CLAIM • Actual date of loss: / / • Approximate time of loss: YES NO am / pm • Was any other party responsible for the loss or damage? • Please describe how the loss occurred (include details of the loss, accident, illness or reason for cancellation): • Are you entitled to claim under any other policy of insurance or private health fund? If YES please give Name & Address: • Have you made any previous claims for Travel Insurance? If YES please give details: YES NO YES NO LUGGAGE AND TRAVEL DOCUMENTS DETAILS • Please give the exact place where the loss of theft happened. • What did you do to recover the lost or stolen item? • If you luggage was lost during a flight or by an airline, please give the name of the airline and the person you contacted. • Contact number for airline • If you reported your loss or theft to someone in authority, please give details (eg police) Reference No. • Address • Give details of Household Contents Insurance Policy No. Name of Station and contact name Telephone Company Item No. 1 2 3 4 5 6 7 Full description of the article(s) claim Name and address where purchased Date of purchase Item No. 1 2 3 4 5 6 7 Only complete this column if the items being claimed for are used in connection with your GST registered business Input tax credit you can claim on the purchase of these items as a % of the total GST payable Original purchase price $ Replacement / repair cost $ ADDITIONAL EXPENSES, TRAVEL DELAY, MISSED CONNECTION, RENTAL VEHICLE EXCESS, CASH IN HOSPITAL, LOSS OF INCOME Details of expenses incurred (if insufficient space please attach list) Date expenses incurred Amount claimed (currency) Type of service • Place and country of circumstances of claim. • If your travel was delayed by your transport provider, did they provide you with alternate accommodation / meals? YES NO RESUMPTION OF JOURNEY, INTERUPTION, CURTAILMENT AND CANCELLATION Details of expenses incurred (if insufficient space please attach list) Date expenses incurred Amount claimed (currency) Type of Service • Was the resumption of journey, interruption and curtailment or cancellation due to your travelling companions or your illness? YES NO If YES, please have the attached Medical Certificate completed. • Was the resumption of journey, interruption, delay or cancellation due to the death, injury or illness of a relative or a business partner? YES NO * If YES, please have the attached Medical Certificate completed. * Name of person Date of Birth Relationship * If it was a death, please supply a full death certificate with the medical certificate. • If you are claiming for cancellation please tell us: Date of cancellation Date your journey was booked MEDICAL EXPENSES Details of expenses incurred (if insufficient space please attach list) Date expenses incurred Amount claimed (currency) Type of Service • If your medical expenses were the result of an illness or the recurrence of an injury, please have the attached Medical Certificate completed. • Place and country where the medical expenses were incurred. • Has the claimant suffered this complaint before? If YES, give details including dates. YES NO Name of person treated Age Relationship to insured Type of injury / illness or disease Date of commencement of injury / illness or disease Name of doctor / hospital Date of first medical consultation “YOUR PRIVACY” We require personal information about You to assess Your Claim. We may disclose Your personal information (other than sensitive information such as health information) to Your adviser, to Our service providers (including loss adjusters and investigators) and Our business partners for this purpose; * We may also disclose personal information including sensitive information about You such as health information to medical practitioners, other health professionals, reinsurers, legal representatives and other consultants. By signing this Claim Form, You consent to Us and those organizations and other professionals collecting and disclosing sensitive information about You; * if You do not provide the requested information or consent to its collection and disclosure as described above, the assessment of Your Claim may be delayed or the Insurer may not pay the Claim; * We may also disclose personal information about You as required or permitted by law; * in most cases, on request, We will give You access to the personal information We hold about You. DECLARATION I / we declare that the answers given on this claim form and that the circumstances surrounding this claim are true and correct and I / we have not withheld any information relevant to the claim of which the Insurer should be made aware. Signed by Assured(s): 1. Date: 2. / / Date: / / MEDICAL CERTIFICATE The following Medical Certificate must be completed by the usual doctor or dentist of the sick or injured person. This applies where cancellation of the journey is a result of your doctor’s recommendation or there has been an early return or request for the resumption of journey following the death, injury or illness of a relative or business partner. If the claim is as a result of illness, the report must be from a doctor who has treated the person for at least 12 months. 1. Name of the person to whom this certificate applies (ie the person whose accident, illness or death caused the cancellation of the holiday) 2. Age Date of Birth 3. Are you the person’s usual medical practitioner? YES NO If so, for how long? 4. Please provide details of the accident or illness. 5. When did the accident happen or the illness commence? 6. a) When were you first consulted for the condition described in question 4? b) In your opinion how long had that condition been present before you were consulted? 7. a) What treatment, if any has the person previously received for that condition or any related condition? b) When did the person receive the treatment? 8. Is the person suffering from any chronic disease or illness or does the person have any other physical defect or disability? YES NO If so, please provide details. 9. Are you prepared to certify that, solely due to the condition described in question 4, the claimant(s) is/are compelled to cancel their holiday arrangements? YES NO - Give details - Give details NO 10. a) At the time the person sought treatment for the condition in question 4, was it life threatening? YES b) Did it become life threatening at any time and, if so, when? YES NO 11. Is the condition in question 4 directly or indirectly related to, or caused by, any other pre-existing condition(s)? YES NO Declaration - medical practitioner The medical practitioner is respectfully requested to give as much detail as possible in order to assist the claimant and avoid the necessity of additional enquiries. I certify that the foregoing statements are correct. Signed Please print name Date Address Qualification