Corporate Travel Insurance Claim Form
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5CORPORATE
Travel Insurance Claim Form
This travel insurance is arranged and managed by Allianz Global Assistance
Postal Address:
Email:
PO Box 33313
corporateclaims@allianz-assistance.co.nz
New Zealand Limited and is underwritten by Allianz Australia Insurance Limited.
Takapuna
Phone: 0800 000 638
Auckland
Facsimile: +64 9 489 8167
New Zealand
Policy No:
Claim No:
Certificate No:
PRIVACY The Privacy Act 1993 requires us to tell you that Allianz Global Assistance as agent for Allianz collect your personal information in order to
handle your claim. We may have to disclose your personal information to third parties such as other insurers, travel agents, medical practitioners,
intermediaries, loss adjusters, external claims data collectors, investigators, or as required by law. You have the right to seek access to your personal
information at any time. Please contact Allianz Global Assistance on 0800 630 117 for access.
Claim Type
Please confirm if claim occurred during Business days
Leisure days
Claimant Details
Name of Claimant (Mr/Mrs/Miss/Ms)
Address
Postcode
Telephone Home
Business
Mobile
Email Address
Date of Birth
/
/
Occupation
Travel Agent
Date of Booking Travel Arrangements
/
/
Date of Departure
/
/
Date of Return
/
/
I / we authorise my broker to act on my behalf if required for this claim.
Broker Details
Broker Name
Address
Postcode
Phone
Mobile
Travel Arrangements
1. Did you use a credit card to purchase your travel (eg. flights, accomodation, tours)?
Yes
No
2. If Yes, please complete the following:
Name on Credit Card
Name of Financial Institution
Card Type:
Visa
Mastercard
Diners
Amex
Card Level:
Gold
Platinum
Other:
Section A. Overseas Medical, Dental and/or Hospitalisation Claim
THE FOLLOWING ITEMS MUST BE INCLUDED WITH THIS CLAIM*
1. Medical/Hospital/Dental Report detailing Treatment and Diagnosis.
2. Itemised accounts giving a breakdown and description of costs claimed, together with receipts if any accounts have been paid by you.
* Failure to provide these documents may result in delays in processing your claim.
Type of Injury or Sickness
Date of Accident or Commencement of Sickness
/
/
If injury – Give full details of Accident
Date of First Medical/Dental Consultation
/
/
Name of Doctor, Dentist and/or Hospital
Details of other treatment by Doctor, Dentist and/or Hospital
Dates in Hospital – Admitted
/
/
am/pm
Discharged
/
/
am/pm
Did you contact our Emergency Assistance department?
Yes
No
Name and Address of usual family doctor
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Parent category: Business