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Reliance Travel Care Policy

Claim Form C
Name of the common carrier

Flight No. From: To:

Please complete the section relevant to your claim

Loss of Total Checked Baggage/ Delay of Checked-in Baggage

1. Nature of Claim Loss Delay

2. Date Time hrs Location_____________ 3. Loss Amount ________________

4. Number of pieces of baggage checked-in 5. Number of pieces of baggage lost/delayed

6. In case of baggage, please specify the following

Scheduled date of Arrival Scheduled time of Arrival hrs

Actual date of Arrival Actual time of Arrival hrs

Number of Hours delayed

(Please provide the details of expenses related to the loss of the checked baggage in the table given below)
Loss of Passport

7. Date Time hrs Location_____________ 8. Loss Amount ________________

9. Passport number

10. Please provide the details of the incident _________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

11. Please provide the details of the Police Report ____________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

12. (Please attach a copy of the Police Report): Reference No.

Date Location
(Please provide the details of expenses related to the loss of Passport & the checked baggage in the table given overleaf)

Loss of International Driving License and Travel Documents

13. Date Time hrs Location_____________ 14. Loss Amount _______________

15. Driving License No.

16. Ticket/Boarding Pass No.

17. Please provide the details of the incident _________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

18. Please provide the details of the Police Report ____________________________________________________________________

__________________________________________________________________________________________________________

19. (Please attach a copy of the Police Report): Reference No.

Date Location

(Please provide the details of expenses related to the loss of International Driving License & Travel Documents in the table given
overleaf)) An ISO 9001:2015 Certified Company

Reliance General Insurance Company Limited. IRDAI Registration No. 103. Registered & Corporate Office: Reliance Centre, South Wing, 4th
Floor, Santacruz (East), Off. Western Express Highway, Mumbai 400055. Corporate Identity No.U66603MH2000PLC128300. UIN
No:RELTIOP08002V010708, RELTIOP07004V010607. Trade Logo displayed above belongs to Anil Dhirubhai Ambani Ventures Private Limited
and used by Reliance General Insurance Company Limited under License. RGI/MCOM/CO/HL-06/CF/VER. 1.5/170820.
 Trip Delay/Cancellation/Interruption/Missed connection
17. c Trip Delay c Trip Cancellation c Trip Interruption c Missed Connections

Reason for Trip delay/Cancellation/Interruption

c Unforeseen Death/Medical Emergency. c Delay by Common Carrier

c Lost or stolen passports, travel documents or money c Natural Disaster in Destination Country

c Inclement weather c Hijack of Common Carrier

c Felonious Assault to Insured Person c Bankrupcy of Common Carrier

c Uninhabitable condition of the place of stay abroad due to fire, flood, vandalism, burglary, or natural disaster

c Abduction/Quarantine of the Insured Person

Type of Trip Interruption : c Curtailment or Shortening of Original Trip c Alteration or Change in Itinerary of Original Insured Trip

18. The person affected Insured Person Immediate Family Member of the Insured Person Traveling Companion

19. If the person affected is not the Insured Person, please provide the following details

Name of the person affected

Address
Flat/Building/Door/Block No.

Road/Street/Sector

Area

Taluka/Village/District/City Pin Code

State Country

Fax

Relationship with the Insured Person ____________________________________________________________________________

20. In case of trip delay and missed connection

Scheduled date of Arrival Scheduled time of Arrival hrs

Actual date of Arrival Actual time of Arrival hrs

Number of Hours delayed

21. In case of missed connection

Date of Departure of Time hrs

Connecting Flight

22. In case of trip cancellation/trip interruption

Date Time hrs

Location

23. Whether accommodation & boarding provided by the carrier? Yes No

Detail of Expenses incurred Date Place Cost

Total
Less Compensation received from the airline
Net Amount

*In case of Delay, please provide details of the purchases made _______________________________________________________

__________________________________________________________________________________________________________

*In case of Loss, please provide details of the items lost _____________________________________________________________

__________________________________________________________________________________________________________
 Hijack Distress Allowance

24. Place of Hijack ______________________________ Date Time hrs

25. Place of Release ____________________________ Date Time hrs

26. Please provide the necessary details of the incident ________________________________________________________________

__________________________________________________________________________________________________________

Personal Liability

27. Please provide the name of third party injured, if applicable ___________________________________________________________

28. Please provide the details of injury/property damaged _______________________________________________________________

__________________________________________________________________________________________________________

29. Please provide the details of the court award ______________________________________________________________________

__________________________________________________________________________________________________________

30. Please specify the details of amount claimed ______________________________________________________________________

__________________________________________________________________________________________________________

31. Date of Loss Place of Loss ___________________________________________________

32. Any other information you would like us to have: ___________________________________________________________________

__________________________________________________________________________________________________________

Emergency Cash Assistance

1. Date on which fund was lost: Place of Loss:_______________________________________

2. FIR Date: FIR Number:________________________________________

3. Details of Incident of loss of fund _______________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

4. Local contact Person (INDIA) who can provide payment security:

Name:

Contact Details: Pan Card Number

5. Please provide the details of the items lost.________________________________________________________________________

__________________________________________________________________________________________________________

Political Risk and Catastrophe Evacuation

1. Please detail out the reason for Evacuation: _______________________________________________________________________

2. Original Travel Schedule Dates: From To:

3. Dates of Evacuation:

4. Location of Evacuation: From To:

5. Details of Losses/ Expenses Incurred:

Detail of Expenses incurred Date Place Cost

Total

Bounced Booking of Airline and Hotel

1. Original Flight Schedule From To:

2. Bounced Flight Booking Date From To:

3. Please share the detailed reason for the Bounced Booking : __________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________
4. Details of Expenses Incurred.
Detail of Expenses incurred Date Place Cost

Total

5. Original Schedule HotelAccommodation: From To:

6. Date for which Hotel booking was bounced: From To:

7. Please share the detailed reason for the Bounced Hotel Booking : ________________________________________________________

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

8. Details of Expenses Incurred.

Detail of Expenses incurred Date Place Cost

Total

Fraudulent Charges (Payment Card Security)

1. Date of Fraudulent Transaction :

2. Total Amount of Fraudulent Transaction:__________________________________________________________________________

3. Name of the Financial Institute: _________________________________________________________________________________

4. Details of Incident of the loss:__________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

Golfer’s Hole in One

1. Date: Golf course name :______________________________________________________________

2. City: _______________________ Country:__________________________________________

3. Total Expenses Incurred: ______________________________

Adventure Sports

Name of the Sport involved : __________________________________________________________________________________

Date & Time of Incidence : ____________________________________________________________________________________

Description of the incidence (Attach as seaprate sheet if required):_____________________________________________________

Date of Birth of Insured : ___________________ Name of The Hospital _______________________________________________

Hospital Address ___________________________________________________________________________________________

Illness/Final Diagnosis given by Treating Hospital/Doctor ___________________________________________________________

Date of Admission ___________________________________ Date of Discharge _______________________________________

Details of the treating Physician _______________________________________________________________________________

Name Address Contact No Registration Number __________________________________________________________________

 Please provide details of the Medical expenses related to your treatment - Should be as below table.

Please provide the details of the expenses related to your treatment

Detail of Expenses In/Out Patient Charges (Currency) Rupees

From To

Paid
Outstanding
Total Due

Contact Reliance General Insurance Company Limited : +91-22-67347843 (Paid) / +91-22-67347844 (Paid)
RCare ID: reliance@europ‐[Link]
UIN No.: RELTIOP08002V010708, RELTIOP07004V010607