Overseas Travel Insurance Claim Form

IMPORTANT:
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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.
Insurance Cert. No./Card No. Period: From: D D M M Y Y Y Y to: D D M M Y Y Y Y

DETAILS OF PATIENT/INSURED PERSON

Name of the Insured

Name of the Employee

Employee No.

Name of the Claimant

Phone Nos.
Permanent Address
(INDIA)
City
State PIN
Phone (O) (R)
Fax Mobile

Bank Account Details: Account Name:

Account No.: IFSC Code
Name of the Bank
& Address

City
State PIN
E-mail
Date of Birth: D D M M Y Y Y Y Marital status: Married Single

Assistance Company Ref No.: __________________________ Passport No.:

Date of Departure: D D M M Y Y Y Y Flight No. __________From _______________ to ______________
Date of Arrival: D D M M Y Y Y Y Flight No. __________From _______________ to ______________

MEDICAL ACCIDENT & SICKNESS BENEFIT/RMR/SICKNESS DENTAL RELIEF/EMERGENCY MEDICAL EVACUATION

If accident, details of accident i.e. how, when, where it took place:

Date: D D M M Y Y Y Y Place:

If sickness, state nature and diagnosis, and advise when & where symptoms first occurred:

Date: D D M M Y Y Y Y Place:
Name & Address of
consulting physician:

City
State PIN
Phone (O) (R)
Fax Mobile

Date: D D M M Y Y Y Y Place:
Have you ever been treated for this illness before: Yes No

If yes, provide
name & address of
consulted physician:
City
State PIN
Phone (O) (R)
Fax Mobile

Provide name &

address of your
family physician:
City
State PIN
Phone (O) (R)
Fax Mobile

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: D D M M Y Y Y Y

Place: Signature of insured :

DETAILS OF MEDICAL EXPENSES

Details of treatment In/Out Patient Charges (Currency) Status of Payment

From To Eg : USD / EURO Paid/Outstanding

Paid
Outstanding

TOTAL

Whether Assistance Co. was contacted: Yes No If Yes, Reference No. ______________________________________________

If No, give reasons:

ATTENDING DOCTOR’S REPORT
Patient Name

Age Marital status: Married Single

Address
City
State PIN
Phone (O) (R)
Fax Mobile
Date of contacted: D D M M Y Y Y Y Time: A.M. P.M.

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:

Is condition due to Pregnancy: Yes No Is illness due to any pre-existing condition: Yes No

Signature:
Attending Doctor’s Signature

LOSS/DELAY OF CHECKED BAGGAGE

Describe when & where the loss/delay took place :

State the extent of Loss: Name the common carrier:

1. Flight No. From to 2. Flight No. From to

Has the common carrier been notified at the time of loss? Yes No Airline Reference No.
Details of compensation received from carrier:
Scheduled date/time of Arrival: D D M M Y Y Y Y hrs.
Actual date/time when bags delivered D D M M Y Y Y Y hrs. No. of Hours delayed : hrs.
Item Purchased/Lost * Date of Purchase Place Cost

TOTAL
Less Compensation received from Airline:
Net Amount
* 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: D D M M Y Y Y Y Place:

Details of Expense Incurred Date Place Amount

TOTAL
TRAVEL DELAY/FLIGHT DELAY
Flight No. Date D D M M Y Y Y Y From to
Scheduled date/time of Arrival: D D M M Y Y Y Y hrs.
Actual date/time when bags delivered D D M M Y Y Y Y hrs. No. of Hours delayed : hrs.
Yes No
Whether accomodation & boarding provided by carrier:
Details of Expense Incurred Date Place Amount

TOTAL
TRIP CANCELLATION/TRIP INTERRUPTION/TRIP CURTAILMENT
Flight No. Date D D M M Y Y Y Y From to

Scheduled time of Departure: hrs. Cause for Cancellation/Interruption/curtailment :

Details of Expense Incurred* Date Place Amount

Amount refunded by Common Carrier and Hotel

TOTAL
*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
Please provide details of injury/property damaged:
Have you received a legal notice, if Yes, please furnish a copy Yes No
BOUNCED BOOKING OF HOTEL AND AIRLINES
Flight No. Date D D M M Y Y Y Y From to
Scheduled date of booking: D D M M Y Y Y Y Cause for bounced booking at hotel/airline:
Details of Expense Incurred* Date Place Amount

Amount refunded by the airline / hotel

TOTAL
MISSED DEPARTURE/MISSED CONNECTION
Flight No. Date D D M M Y Y Y Y From to
Scheduled date/time of Arrival: D D M M Y Y Y Y hrs.
Actual date/time when bags delivered D D M M Y Y Y Y hrs. No. of Hours delayed : hrs.
Yes No
Whether accomodation & boarding provided by carrier:
Details of Expense Incurred* Date Place Amount

TOTAL
HIJACKING
Flight details No. From to
Scheduled date/time of Departure: D D M M Y Y Y Y hrs. Date & time of Hijack D D M M Y Y Y Y hrs.
Scheduled date/time of Arrival: D D M M Y Y Y Y hrs. Date & time of Returned D D M M Y Y Y Y hrs.
Please provide details of incident:
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.
Date D D M M Y Y Y Y
Place Signature
Disclaimer: Insurance is the subject matter of solicitation
Tata AIG General Insurance Company Limited
Tata
Registered office: Peninsula Business AIG
Park, TowerGeneral Insurance
A, 15th Floor, Company
G. K. Marg, Off SenapatiLimited
Bapat Road, Lower Parel, Mumbai - 400 013.
For more information
Registered visit us at;
Office: Peninsula Email Park,
Business us at Tower
customersupport@[Link] or visit
A, 15th Floor, G.K. Marg, Lower [Link]
Parel, Mumbai – 400013.
24x7 TollContact us1800
Free No: on our 247780
266 hour or
Toll Free229966
1800 Helpline at 1800
(For Senior266 7780 or| 1800
Citizens) 22 9966
Fax: 022 6693(only
8170for| senior citizen policy holders)
Email: customersupport@[Link]
Website: [Link] | IRDA of IndiaInsurance is the
Registration No:subject
108 | matter of the solicitation
CIN:U85110MH2000PLC128425 | UIN: TATTIOP21202V022021