Corporate Travel Insurance Claim Form (Page 2 of 5) in pdf

Please list each receipt/bill separately in the table below. Claims will be converted to New Zealand dollars using the currency rate applicable at the

date and time the expenses were incurred.

Name of Doctor/Dentist/Pharmacy/

Date of

Amount Charged

Refund from

Treatment Performed

Paid Yes/No

Hospital or Provider

Treatment

(State Currency)

Health Funds

e.g. Doctor R Smith

e.g. Consultation

e.g. 10/02/07

e.g. EUR 100

e.g. Yes

e.g. EUR 75

Section B. Cancellation Charges / Loss of Deposit Claim / Additional Expenses

THE FOLLOWING ITEMS MUST BE INCLUDED WITH THIS CLAIM*

1. Copy of original Itinerary.

2. Letter from Travel Agent or, where travel was not arranged through a Travel Agent, a letter from the relevant organisation through whom travel

was booked, confirming payments made, refunds given and any amounts you are out of pocket.

3. Proof of payment for trip (ie. receipts, credit card/bank statements showing payments made).

4. If travel was cancelled due to Medical Reasons/Death – please provide a medical certificate or a copy of Death Certificate (if applicable).

5. If travel was cancelled by a Transport Provider – letter from them explaining the circumstances of the cancellation and any refund/

compensation paid or payable to you.

What was the reason why you could not commence or complete your proposed Journey?

Was your Journey cancelled as a result of Injury/Sickness to any other person?

Yes

If Yes, please provide

Full Name

Date of Birth

Address

Relationship

Nature of Injury/Sickness

Date your Journey was booked:

Date your Journey was cancelled

Details of Journey

Date

Description of Booking

Supplier

Amount Paid

Refund Received

Amount Claimed

Please state the reason/event that caused the additional expenses being incurred

What was the unexpected expense incurred?

Please list each receipt/bill separately in the table below. Claims will be converted to New Zealand dollars using the currency rate applicable at the

date and time the expenses were incurred.

Date of Expense

Description of Expense

Amount

Date of Original Plan

Description of Original Cost

Amount

e.g. 24/07/07

e.g. Hotel in Paris

e.g. EUR 100

e.g. 24/07/07

Flight to Munich