Overseas Travel Insurance
Claim Form
IMPORTANT:
Please contact our 24-hour helpline (our Assistance Center) on
For excluding the Americas Policies : Call:+91 – 022 68227600
Email - [email protected]
For the Americas Policies: Please call: +1-833-440-1575 (Tollfree within US and Canada)
Email - [email protected]
Failure to call our Assistance Company on 24-hour helpline, in respect of Medical Accident & Sickness Claims shall invalidate your claim, if any.
1. This is a One Call Claim Form, except for Accidental Death & Dismemberment (ADD). For ADD, we shall provide a separate Claim Form upon
notification.
2. Issuance of the form is not an admission of liability or a waiver of terms, conditions & exceptions of the insurance contract.
3. No claim under Accident & Sickness Section will be admitted without Doctor’s Report as per format (Attending Doctor’s Report - Page 3)
4. Please answer all questions completely. In case of insufficient space, please attach an additional sheet.
5. Please attach all Original bills & receipts pertaining to your claim.
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Insurance Cert. No./Card No.
Period: From: to:
Name of the Insured
Name of the Employee
Name of the Claimant
Employee No.
Phone Nos.
Permanent Address
(INDIA)
PIN
PIN
State
State
Phone (O)
Fax
City
City
E-mail
Account Name:
Account No.:
IFSC Code
Bank Account Details:
(R)
Mobile
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Single
DETAILS OF PATIENT/INSURED PERSON
MEDICAL ACCIDENT & SICKNESS BENEFIT/RMR/SICKNESS DENTAL RELIEF/EMERGENCY MEDICAL EVACUATION
Marital status:
Date of Birth:
Married
Name of the Bank
& Address
Assistance Company Ref No.: __________________________ Passport No.:
Date of Departure: Flight No. __________From _______________ to ______________
Date of Arrival: Flight No. __________From _______________ to ______________
If accident, details of accident i.e. how, when, where it took place:
If sickness, state nature and diagnosis, and advise when & where symptoms first occurred:
Date:
Date:
Place:
Place:
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Name & Address of
consulting physician:
Date: Place:
Have you ever been treated for this illness before:
Yes
Yes
No
No
PIN
PIN
PIN
State
State
State
Phone (O)
Phone (O)
Phone (O)
Fax
Fax
Fax
City
City
City
(R)
(R)
(R)
Mobile
Mobile
Mobile
If yes, provide
name & address of
consulted physician:
Provide name &
address of your
family physician:
Provide name of any prescription medicine you are presently taking:
Indicate other health insurance coverages, including name, address, policy number & certificate number of insurer:
AUTHORIZATION
I hereby authorize any hospital, physician, or other person who has attended or examined me, to furnish to the company, or its authorized
representative, any and all information with respect to any illness or injury, medical history, consultation, prescriptions or treatment and
copies of all hospital or medical records, a photostat copy of this authorization shall be considered as effective and valid as the original.
Date:
Place: Signature of insured :
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DETAILS OF MEDICAL EXPENSES
Details of treatment
In/Out Patient
Status of PaymentCharges (Currency)
From
To
Eg : USD / EURO Paid/Outstanding
TOTAL
Outstanding
Paid
If Yes, Reference No. ______________________________________________
Whether Assistance Co. was contacted:
If No, give reasons:
ATTENDING DOCTOR’S REPORT
PIN
State
Phone (O)
Fax
City
(R)
Mobile
Patient Name
Address
Date of contacted:
Time: A.M. P.M.
Single
Marital status:
Married
Age
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FOR ACCIDENTAL INJURY/SICKNESS
Nature of Injury/sickness :
Details of incidence:
Diagnosis and Treatment given:
When did patient’s symptoms first appear:
Describe any other disease or infirmity affecting present condition:
Signature:
Attending Doctor’s Signature
Is illness due to any pre-existing condition:
Is condition due to Pregnancy:
Yes Yes
No No
LOSS/DELAY OF CHECKED BAGGAGE
Describe when & where the loss/delay took place :
State the extent of Loss:
1. Flight No.
From
to
Name the common carrier:
2. Flight No.
From to
Has the common carrier been notified at the time of loss?
Yes
No
Airline Reference No.
Scheduled date/time of Arrival:
Actual date/time when bags delivered
No. of Hours delayed :
Details of compensation received from carrier:
hrs.
hrs. hrs.
Item Purchased/Lost *
Date of Purchase Cost
Place
Net Amount
Less Compensation received from Airline:
TOTAL
* In case of Delay, please provide details of purchases made
* In case of Loss, please provide details of items lost.
LOSS OF PASSPORT
Please provide details of the incident i.e. when, where and how it happened:
Details of Police Report (please attach copy): No:
Date: Place:
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Details of Expense Incurred
Date Amount
Place
TOTAL
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TRAVEL DELAY/FLIGHT DELAY
Details of Expense Incurred
Date Amount
Place
TOTAL
Flight No.
Flight No.
Flight details No.
Date
Date
From
From
From
to
to
to
Whether accomodation & boarding provided by carrier:
Whether accomodation & boarding provided by carrier:
Yes
Yes
Yes
No
No
No
TRIP CANCELLA TION/TRIP INTERRUPTION/TRIP CURTAILMENT
Details of Expense Incurred*
Details of Expense Incurred*
Details of Expense Incurred*
Date
Date
Date
Amount
Amount
Amount
Place
Place
Place
TOTAL
TOTAL
TOTAL
Amount refunded by Common Carrier and Hotel
Amount refunded by the airline / hotel
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Flight No.
Scheduled time of Departure:
Date
Cause for Cancellation/Interruption/curtailment :
From
to
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Flight No.
Scheduled date of booking:
Date
Cause for bounced booking at hotel/airline:
From
to
*Please note that this coverage applies if Trip is cancelled due to Illness, Injury or death to: You; Your Traveling Companion; Your Immediate
Family Member.
PERSONAL LIABILITY
BOUNCED BOOKING OF HOTEL AND AIRLINES
MISSED DEPARTURE/MISSED CONNECTION
HIJACKING
Please provide details of injury/property damaged:
Have you received a legal notice, if Yes, please furnish a copy
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Scheduled date/time of Arrival:
Scheduled date/time of Arrival:
Scheduled date/time of Departure: Date & time of Hijack
Scheduled date/time of Arrival:
Date & time of Returned
Actual date/time when bags delivered
Actual date/time when bags delivered
No. of Hours delayed :
No. of Hours delayed :
hrs.
hrs.
hrs. hrs.
hrs.
hrs.
hrs.
hrs.
hrs.
hrs.
hrs.
Please provide details of incident:
Date
I declare that the above answers are true and correct to the best of my knowledge and that I have not withheld any relevant information
which might have otherwise affected the acceptance of my application. I understand and agree that the insurance applied for will become
effective only upon acceptance by the company and the premium being fully paid.
Signature
Place
Registered oce: Peninsula Business Park, Tower A, 15th Floor, G. K. Marg, Off Senapati Bapat Road, Lower Parel, Mumbai - 400 013.
Tata AIG General Insurance Company Limited
For more information visit us at; Email us at [email protected] or visit www.tataaiginsurance.in
Contact us on our 24 hour Toll Free Helpline at 1800 266 7780 or 1800 22 9966 (only for senior citizen policy holders)
Insurance is the subject matter of the solicitation
Disclaimer: Insurance is the subject matter of solicitation
Registered Office: Peninsula Business Park, Tower A, 15th Floor, G.K. Marg, Lower Parel, Mumbai – 400013.
24x7 Toll Free No: 1800 266 7780 or 1800 229966 (For Senior Cizens) | Email: customersupport@tataaig.com
Website: www.tataaig.com | IRDA of India Registraon No: 108 | CIN:U85110MH2000PLC128425 | UIN: TATTGOP23085V022223
Tata AIG General Insurance Company Limited