Travel Accident Insurance Claim Form

Policy Number

Full Name Date of Birth Contact Number Email Address Address

Trip Destination Trip Dates Purpose of Trip

Date of Accident Location of Accident Description of Accident Details of Injury

Hospital/Clinic Name Hospital/Clinic Address Date of Admission Date of Discharge

Police Report Filed? Yes No Witness Details (if any)

Other Insurance Coverage? Yes No If Yes, Provide Details

Bank Account Details for Payment

Declaration Signature Date