Travel Insurance Loss Claim Document
Policyholder Information
Full Name
Policy Number
Contact Number
Email Address
Address
Travel Details
Destination(s)
Departure Date
Return Date
Loss or Incident Details
Date of Loss
Location of Loss
Detailed Description of Loss / Incident
Estimated Loss Amount
Reported to Authorities?
If yes, provide Authority Name & Report Number
Bank Details (for Claim Payment)
Account Holder Name
Bank Name
Account Number
IFSC / SWIFT Code
Declaration
I declare that the statements made are true to the best of my knowledge and belief.
Signature
Date