Medical Emergency Travel Insurance Claim
1. Personal Details
Full Name
Policy Number
Date of Birth
Email Address
Contact Number
Home Address
2. Travel Information
Destination Country
Travel Dates
Date of Incident
3. Medical Details
Nature of Illness/Injury
Name & Address of Hospital/Clinic
Name of Treating Doctor
Details of Treatment Received
4. Claim Details
Total Amount Claimed
Currency
Bank Account Details for Reimbursement
5. Declaration
I declare that the information provided is true and complete.
Signature
Date