Travel Insurance Proof of Loss Report
Policyholder Name
Policy Number
Contact Information
Travel Dates
Departure Date
Return Date
Destination
Description of Loss / Incident
Date of Loss/Incident
Location of Loss/Incident
Items Lost, Damaged, or Expenses Incurred
Were local authorities notified?
Yes
No
If yes, provide report/reference number
Other Insurance Coverage (if any)
Declaration & Signature
Signature
Date