Pregnancy-Related Travel Insurance Claim Form
Personal Details
Full Name
Date of Birth
Address
Phone Number
Email
Policy Details
Policy Number
Policy Holder Name
Travel Details
Trip Start Date
Trip End Date
Travel Destination(s)
Purpose of Travel
Pregnancy Information
Expected Due Date
Weeks Pregnant at Start of Trip
Any Complications?
Yes
No
Attending Doctor's Name
Medical Center/Clinic
Claim Details
Nature of Claim
Trip Cancellation
Trip Interruption
Medical Expenses
Other
Claim Amount ($)
Details of Incident
Bank Details (for Payment)
Bank Name
Account Holder Name
Account Number
IFSC/Swift Code
Declaration & Signature
I declare that the above information is true and correct to the best of my knowledge.
Signature
Date