Please note if you are claiming for various incidents then you will need to tick each relevant claim type and complete the sections accordingly.
Cancellation or postponement of trip
Medical, Emergency Dental, Hospital and/or Other Expenses relating to a medical incident and/or Expenses incurred due to Curtailment (Early return home from your trip)
Missed Departure, Delayed travel or Abandonment of your trip due to Delayed Travel
Loss, theft or damage to Baggage (including delayed baggage), Valuables, Money and Documents
Costs incurred due to Catastrophe
Car Rental Excess Waiver (Damage to Rental Vehicle)
Additional Expenses incurred or any other incident not outlined above
If Cancellation/Postponement is due to Medical reasons, please download and complete the Medical Certificate before proceeding with this form.
PLEASE READ THE CLAIM FORM CAREFULLY.
- The issue of this claim form does not constitute an admission of liability
- Omission of relevant information may delay your claim
Describe fully the circumstances of the incident, which has led you to make the claim(s):
NOTE: It is vital that you explain as carefully as you can, the specific circumstances leading up to and following the incident.
Trip cancelled for Medical Reasons – Note: The regular medical practitioner of the ill/injured/deceased person must complete the attached certificate.
Full name of ill/injured/deceased person
Trip cancelled for non-medical reasons – Supply evidence to support the reason
Name of all persons cancelling or postponing this holiday, (including the claimant), and their relationship to the ill/injured/deceased person:
Identify all persons for whom emergency expenses have been incurred:
Identify all persons for whom expenses have been incurred:
Please list all persons claiming:
Travel Itinerary/Schedule as originally booked:
Amended Travel Schedule as a result of delay:
At what place, date and time was the property last seen and know to be undamaged:
Please note if you have named any Valuables as gifts: If possible, we request that you obtain a Statutory Declaration from the person who gave you the items, detailing the date, cost and place of purchase to prove ownership. If you have alternative proof of purchase, this is not required.
Please give specific details of any irrecoverable expenses or additional expenses incurred as a result of the catastrophe:
At what place, date and time was the vehicle last seen and known to be undamaged:
At what place, date and time was the vehicle discovered missing or damaged:
If claiming for lost/stolen/damaged items, complete all fields. If claiming Delayed Baggage, complete fields, 1, 3, and 6. If Claiming for additional Expenses, completed fields 1 and 6. Reimbursement will be based on the value of the property at the time of loss or damage.
I/We have completed the Claim form and declare it to be true and accurate and am enclosing the documents as requested to support this claim. I subrogate to my Insurer all rights of recovery/salvage against any person or organization and will do whatever else is necessary to secure such rights. With regards to any MEDICAL, CURTAILMENT & EMERGENCY CLAIMS I give authority to Insurers or their representatives to contact my Doctor if need be, for any additional medical information required in connection with this claim. I authorise any hospital, physician or other person who attended me, to give my travel insurance company or its representative, any, or all information, with respect to any sickness or injury, medical history, consultation, prescription, or treatment, and copies of all hospital or medical records.
I/We authorise Gallagher Bassett to transfer any settlement amount into the account outlined above.
I/We have the consent of each person who is insured on this Policy and making a claim in relation to this event (if they have been included in this claim form) for settlement monies to be transferred into the above account.
I/We acknowledge that payment of any unpaid accounts will be issued to the provider.
* Please consult your PDS for the privacy statement of your insurer.
Original Travel Itinerary also showing amounts paid for the trip:
Letter from Airline(s)/Tour Operator(s)/Accommodation Provider(s) confirming amount of refund(s):
Medical Certificate completed by the regular medical practitioner of the ill/injured/deceased person:
Full evidence to support the requirement to Cancel or Postpone:
Full Death Certificate (if applicable):
Medical Certificate completed by the treating doctor/hospital:
Original receipts and/or invoices for all Medical/Travel/Accommodation or Other Expenses claimed:
Receipts of any expenses outlaid:
Documentation from Third Party detailing the costs they are pursuing and why, i.e. Letter of Demand:
Police Report (if applicable):
Travel Itinerary detailing all stages (departure and arrival times) of your Trip:
Confirmation from the airline/tour operator or similar of, detailing the reason for delay and subsequent departure times:
Invoices or receipts for additional costs incurred:
Confirmation from airline/tour operator confirming the delay/cancellation of services and whether any refund is applicable:
Copy of the motorists’ emergency service or Police report confirming the details if the delay is a result of a vehicle breakdown/accident:
Proof of Value and Ownership in the form of receipts or other documentation including manuals, warranties, photographs and valuations:
Two (2) replacement quotes for the same or similar model:
In respect of all claims for damage, letter from a repairer confirming cause and extent of damage
A written report to confirm notification of damage/loss and non-recovery from Airline/Hotel/Courier/Ships Purser or other applicable authority:
In respect of all claims for stolen items a Police Report:
Documentation in support of cash claimed, eg. ATM withdrawal slips, bank statements, foreign exchange transactions:
Invoices/Receipts regarding the replacement of any Document i.e. Passport, Airline Tickets etc:
Detailed travel itinerary:
Property Irregularity Report from the at fault airline:
Receipts for ALL emergency purchases made:
Original Travel Itinerary also showing amount paid for the trip:
Booking Conditions of flights/trip/accommodation:
Letter from Airline/Tour Operator/Travel Agent confirming amount of refund (if any):
Receipts/Bank Statements or other documentation showing the purchase of pre-booked accommodation:
Directive in writing from local or national authority deeming that you are forced to move from you pre-booked accommodation:
Receipts/Bank Statements or other documentation detailing any extra expenses incurred:
Hire/Rental Vehicle documentation evidencing details/conditions of hire/rental:
Documentation/receipts evidencing all amounts paid in respect of hire/rental vehicle (including insurance component and applicable Excess/damages):
Airline Tickets/Prepaid tickets:
If you have any questions or require any assistance please do not hesitate to call on +61 7 3005 1613. Alternatively send an email to email@example.com and we will respond within 48 hours.
Thank you for submitting your application. A copy has been sent to you for your records.
The team will process your claim and be in touch over the next couple of working days. If you have any queries please contact us on firstname.lastname@example.org
The following required documents have not been attached. You may still proceed with your application but it is recommended that you include all required documents.