Skip to Content »

Claim Documents

Here you will gain easy access to important travel claim forms. Fill them out and mail or fax them back to our claims office.

Note: You will need Acrobat Reader to view and print the forms.

Instructions on the claim forms will assist you in completing the forms. Please attach all supporting documentation.


Claim Form Document Center

Select any form below to download a printable version. These documents are in Adobe Acrobat format and are best viewed using Adobe Reader 5.0 or higher.

Click topics below for complete descriptions and forms:

Trip Cancellation Claims
- Trip Cancellation Form
- Attending Physician's Statement (need to include patient planholder authorization portion)

Trip Delay Claims
- Trip Delay Claim Form

Trip Interruption Planholders / Patient Statement
- Trip Interruption Planholder/Patient Statement
- Attending Physician's Statement

Medical Expense Claims
- Medical Expense Claim Form
- Planholder/Patient Statement Claim Form

Baggage Delay Claims
- Baggage Claim Form

Claims Explanations

back to top

Trip Cancellation Claims

What is needed:

Complete cancellation of your travel arrangements:
  • E-ticket receipt or original paper ticket from airline. International tickets require a written statement from the airline on ticket refundability.
  • The Attending Physician's Statement completed in full by the patient's physician.
  • Sign and complete Planholder/Patient Statement.
  • Cancelled checks or credit card statements showing all payments for your trip. If you paid cash, you must send a receipt from the travel coordinator/tour operator indicating the date and the amount paid for the trip.
  • Credit card statements reflecting any credit transactions or a written statement from a travel agent or tour operator indicating why no refund was received.
  • Please include proof of insurance payment.
  • Please enclose a copy of the trip flyer and/or brochure
  • If death is the reason for claim, please provide a full copy of death certificate.
Forms

PDF Trip Cancellation Claim Form
PDF Attending Physician's Statement


back to top

Trip Delay Claims

What is needed:

Additional Transportation:
Please supply the following:
  • Please provide us with written verification from the common carrier as to the cause and length of the delay.
  • Please provide us with proof of payment for additional transportation expenses. i.e. invoices or receipts and a copy of your cancelled check or credit card statement showing payment for the additional expenses.
  • Please provide us with proof of payment for additional accommodations and meal expense. i.e. Invoices or receipts and a copy of your canceled check or credit card statement showing payment for the additional expenses.
Unused, prepaid nonrefundable portions of your missed trip:
Please supply the following:
  • Please provide us with written verification from the common carrier as to the cause and length of the delay.
  • Please provide us with a copy of your trip itinerary.
  • Please have the Travel Coordinator's Statement completed by your travel coordinator for the prepaid unused nonrefundable portion of your land/sea that was missed. Please be sure that the land and sea arrangements are broken down.
Forms

PDF Trip Delay Claim Form


back to top

Trip Interruption Planholders/Patient Statement

What is needed:

Additional Transportation:
  • The Planholder/Patient Statement completed and signed.
  • Verification of the reason your trip was interrupted. If interruption was due to a medical reason, please submit proof of medical treatment at the point of interruption.
  • If death is the reason for claim, please provide a copy of death certificate.
  • The original unused airline tickets, or original e-ticket.
  • Receipts verifying extra incurred expenses for transportation to return to final destination (i.e. airline tickets, train, or bus tickets).
  • Canceled checks or credit card statements showing the purchase of all travel arrangements and Property Management Co. invoices.
Forms

PDF Trip Interruption Planholder/Patient Statement
PDF Attending Physician's Statement


back to top

Medical Expenses Claims

What is needed:

  • Your cancelled check or credit card statement for the initial trip deposit.
  • Verification of medical treatment, such as detailed medical statements from the treating physician indicating where and when the accident or sickness occurred.
  • Copies of all medical bills incurred while on your trip.
  • If patient received follow-up treatment upon returning home, please have the Attending Physicians Statement completed in full by the patient's physician.
  • Completed and Signed Planholder/Patient Statement
  • Verification of your travel arrangements. (i.e., copy of ticket, brochure, invoice, itinerary).
  • Credit card statement, cancelled checks or cash receipt for all medical payments while on your trip.

Please attach all other insurance explanation of benefits reflecting medical expenses incurred on your trip.

Forms

PDF Medical Expense Claim Form
PDF Planholder/Patient Statement Claim Form


back to top

Baggage Delay Claims

What is needed:

Please supply the following:
  • Written statement from common carrier regarding baggage delay and length of delay.
  • Receipts for necessary purchases.
  • Copy of passenger ticket.
  • Keep a photocopy of this completed form and all attachments for your records.
  • Sign and date completed claim form.
Forms

PDF Baggage Claim Form