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

Medical Authority and Declaration

I DECLARE THAT:

•

I will use my best endeavours and render all reasonable assistance and co-operation to Allianz Global Assistance in the assessment of my claim;

•

The information supplied by me is true and correct and I have not withheld any information likely to affect the assessment of my claim;

•

I understand that the claim may be denied if the information supplied is untrue, or I have not revealed all relevant facts;

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I understand that by investigating my claim or by accepting proofs of my claim, Allianz Global Assistance has made no acceptance of liability,

nor waived any of its rights in defence of any claim arising under the policy;

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A photocopy of this Authorisation shall be considered as effective and valid as the original and I specifically authorise its use as such.

I appoint Allianz Global Assistance to do everything necessary or expedient to:

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give effect to the transactions contemplated by the authorisations described; and

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execute and deliver any other documents or do any other acts referred to in the transactions described.

I authorise any person, corporation, institution, private or government organisation, whether named by me or not, to provide such information

as Allianz Global Assistance in its absolute discretion considers relevant for its assessment of initial or ongoing benefits for my claim including,

without limitation:

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all medical, surgical or other information concerning myself, my medical history, any treatment received by me and any medication taken or

prescribed for me (at any time);

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my Health Insurance claims history;

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any information in relation to my assets, liabilities, earnings, salary or wages (at any time);

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any information from third persons who may have information relevant to my eligibility to receive a benefit, or my entitlement to receive an

ongoing benefit.

Signature of Claimant

Date

Name of Claimant

Signature of Witness

Date

Name of Witness

Page 5 of 5

Corporate Travel Insurance Claim Form Page 5