Travel Insurance Medical Expense Claim Form
1. Insured Person Details
Full Name
Date of Birth
Policy Number
Contact Number
Email Address
Address
2. Trip Details
Travel Destination(s)
Departure Date
Return Date
3. Medical Expense Claim Information
Date of Illness/Injury
Country Where Treated
Name of Treating Doctor/Hospital
Total Amount Claimed
Description of Illness/Injury and Treatment Received
4. Bank Account Details for Payment
Account Holder Name
Bank Name
Account Number
Sort Code / SWIFT / IBAN
5. Declaration
Name
Date
Signature