CLAIMS FORM FOR OVERSEAS TRAVEL INSURANCE
In the event of a claim, contact our 24-hour helpline numbers
In USA +1 877 352 7706 (Toll Free)
In Canada +1 877 352 7693 (Toll Free)
From the rest of the World +91 22 6787 2010(Call Back Facility)
In India 1800 209 8889 (Toll Free & Accessible in India only)
Fax +91 22 6734 7888
E-mail
Claims Processing Department Address ICICI Lombard General Insurance Company Limited
C/O Europ Assistance India Pvt Ltd. 301, C Wing, Business
Square, Andheri Kurla Road,Chakala, Andheri East
Mumbai – 400093 India
icicilombard [at] europ-assistance [dot] in
Policy No.: ________________________________
Policy Start Date: _________________________________ Policy End Date: ____________________________ __________________
Full Name: ________________________________________________________________________________________________
Date of Birth:InformationInformation_Information/InformationInformation_Information/InformationInformation_Information_Information_Information Sex: Information Information /Information Information
Current Address: ___________________________________________________________________________________________
Address in Country of Residence:________________________________________________________________________________
Phone No Overseas: _________________________________________________________________________________________
Phone No India: ____________________________________________________________________________________________
Mobile No: ________________________________ Email ID: _________________________________________________________
Passport No.: ______________________________________________________________________________________________
Claims Ref No.:(As provided)___________________________________________________________________________________
Date of Departure from Country of Residence: InformationInformation_Information/InformationInformation_Information/InformationInformation_Information_Information_InformationFlight No. _________ From ________ to ____________
Date of Arrival back to Country of Residence: InformationInformation_Information/InformationInformation_Information/InformationInformation_Information_Information_Information Flight No. _________ From _________ to __________
Every claim has to be accompanied with original ticket/boarding pass or copy of the passport indicating the travel dates.
M F
DETAILS OF INSURED
(If different than “Insured Information” above)
Full Name: ________________________________________________________________________________________________
Date of Birth:InformationInformation_Information/InformationInformation_Information/InformationInformation_Information_Information_Information Sex: Information Information /Information Information
Relationship with the Policyholder: InformationInformation_Information_Information_Information_Information_Information_Information_Information_Information
Claimant's Address: _________________________________________________________________________________________
Phone No. (Off): InformationInformation_Information_Information_Information_Information_Information_Information_Information_Information_Information Phone No. (Res): InformationInformation_Information_Information_Information_Information_Information_Information_Information_Information_Information
Email ID: _________________________________________________________________________________________________
In what capacity are you making this claim?
M F
CLAIMANT INFORMATION
AUTHORIZATION BY INSURED / ON BEHALF OF THE INSURED
I authorize any insurance company, physician, hospital or other healthcare provider, or any other organization, institution or person that may have records, documents or knowledge
regarding the Insured to release any information requested regarding this claim and the loss reported. I understand ICICI Lombard General Insurance Company Ltd, or its authorized
representatives, for the purpose of evaluating and determining coverage for this claim, will use this information. I know I have a right to receive a copy of this authorization upon request
and agree that a photographic or facsimile copy of this authorization is as valid as the original. I agree that this authorization shall be valid for the duration of this claim. I also authorize
ASP, on behalf of ICICI Lombard General Insurance Company Limited, to obtain any medical records or information to process this claim. I understand that any person who knowingly and
with intent to defraud or deceive any insurance company files a claim containing any materially false, incomplete or misleading information may be subject to prosecution for insurance
fraud.
SIGNED (Claimant or authorized person) Relationship with the Insured
Dated : ________________ Place :____________________ Proposers Signature : ________________________________________
Sr. No. Details of treatment/expenses Date Expenses in Foreign Currency
Total:
MEDICAL TREATMENT EXPENSES DETAILS
1. MEDICAL COVER & DENTAL TREATMENT
Out Patient Treatment
Nature of Ailment:
State Diagnosis and nature of treatment taken: ________________________________________________________________________
Dates of treatment: From Information Information_ Information/Information Information_ Information/Information Information_ Information_ Information_ Information To: Information Information_ Information/Information Information_ Information/Information Information_ Information_ Information_ Information
Date of onset of symptoms:Information Information_ Information/Information Information_ Information/Information Information_ Information_ Information_ Information
Name, address & telephone number of consulting physician/dentist/hospital where treatment was taken:
Have you ever been treated for this illness before: Information Information_ Information
If yes, provide name, address & telephone number of consulted physician: ____________________________________________________
Provide name, address & telephone number of your family /regular doctor in India: ______________________________________________
Provide name of any prescription medicine you are presently taking: Information______________________________________________________
Hospitalisation
Full Name: _________________________________________________________________________________________________
Address: ___________________________________________________________________________________________________
Phone Number of Hospital / Clinic: ____________________________________________
Treating Doctor's Name & Qualifications: ___________________________________________________________________________
Treating Doctor's Telephone Number: (O) InformationInformation_Information_Information_Information_Information_Information_Information_Information_Information_Information (M)InformationInformation_Information_Information_Information_Information_Information_Information_Information_Information_Information
Room / Ward / Bed Number: ____________________________________________________________________________________
Dates of Treatment: From :Information Information_ Information/Information Information_ Information/Information Information_ Information_ Information_ Information To: Information Information_ Information/Information Information_ Information/Information Information_ Information_ Information_ Information
Date of onset of Symptoms:Information Information_ Information/Information Information_ Information/Information Information_ Information_ Information_ Information
Attending Doctor's Report
Date Doctor Contacted:Information Information_ Information/Information Information_ Information/Information Information_ Information_ Information_ Information Time:Information Information_ Information : Information Information_ Information
Nature of Ailment: ___________________________________________________________________________________________
State diagnosis and nature of treatment provided: ___________________________________________________________________
When did patient's symptoms first appear? ________________________________________________________________________
Describe any other disease or infirmity affecting present condition: ______________________________________________________
Was the ailment due to Pregnancy: Information Information_ Information
Was the ailment aggravated due to any pre-existing condition? Information Information_ Information
If yes, please give details:
Can the patient be evacuated back to the Republic of India? Information Information_ Information
Is Medical Evacuation back to Republic of India needed? Please give detailed reasons of the ailment and reason for transportation:
________________________________________________________________________________________________________
____________________________________________________________________________________________
2. REPATRIATION OF REMAINS
Cause / Circumstances of death:___________________________________________________________________________________
Date of death of Insured: Information Information_ Information/Information Information_ Information/Information Information_ Information_ Information_ Information
Details of expenses incurred for repatriation of Remains / Funeral:
D D M M Y Y Y Y
Sr. No. Details of expenses Date Expenses in Foreign Currency
Total:
Documents to be submitted in support of the claim:
1. Photocopy of the death certificate providing the details of the place, date and time, and the circumstances and cause of the death (photocopy of
the postmortem certificate wherever required by the Assistance Service Provider), issued by the appropriate authority where the contingency
has arisen.
2. Proof for expenses incurred towards disposal of the mortal remains.
3. In case of transportation of the body of the deceased to the Country of Residence of the Insured, the receipt for expenses incurred towards
preparation and packing of the mortal remains of the deceased and also for the air transportation of the mortal remains of the deceased to the
Claiming also for daily allowance
Documents to be submitted in support of the claim:
1. Medical reports and discharge summary issued by the Hospital furnishing the name of the Insured, period of treatment, details of treatment
rendered.
2. Bills / receipts for:
a. Charges paid towards Hospital accommodation, nursing facilities and other medical services rendered;
b. Fees paid to the Medical Practitioner, special nursing charges, etc.
c. Charges incurred towards any and all test and / or examinations rendered in connection with the treatment.
d. Charges incurred towards medicines or drugs purchased from outside duly supported by the prescriptions of the Medical Practitioner
attending on the Insured.
In respect of all claims payable hereunder, the Company may effect settlement either in the form of cashless treatment facility or by reimbursement
3. CHECKED-IN BAGGAGE LOSS/ DELAY
Describe when & where the Loss / Delay took place:
State the extent of Delay / Loss: ____________________________________________________________________________________
Name the common carrier: _______________________________________________________________________________________
Flight Details:
1.Flight No.: From InformationInformation_Information/InformationInformation_Information/InformationInformation_Information_Information_Information To: InformationInformation_Information/InformationInformation_Information/InformationInformation_Information_Information_Information
2.Flight No.: From InformationInformation_Information/InformationInformation_Information/InformationInformation_Information_Information_Information To: InformationInformation_Information/InformationInformation_Information/InformationInformation_Information_Information_Information
Port of Delay / Loss: _____________________________________________________________________________________________
Actual Date & Time of Arrival of flight at Port: DD / MM / YYYY HH:MM
Actual Date & Time when Bags were delivered: Information Information_ Information/Information Information_ Information/Information Information_ Information_ Information_ Information Time:Information Information_ Information : Information Information_ Information
No. of Hours of bag delay: ________________________________
Had the common carrier been notified at the time of loss? Information Information_ Information
Property Irregularity Report (PIR) number from Airline: ___________________________________________________________________
_____________________________________________________________________
D D M M Y Y Y Y H H M M
Y N
Sr. No. Item Purchased / Items Lost Date of Purchase Cost in Foreign Currency (In INR for loss claim)
Total:
Compensation From Airlines:
Net Amount:
Documents to be submitted in support of the claim for Checked-in Baggage Loss:
1. Statement of claim furnishing the details of items contained in the Checked-In Baggage and the values thereof (excluding Valuables). Values of
the items shall represent their market value after allowing for age and usage.
2. Property irregularity report issued by the Common Carrier.
3. Voucher of the Common Carrier for the compensation paid for the non-delivery / short delivery of the Checked-In Baggage.
4. Copies of correspondence exchanged, if any, with the Common Carrier in connection with the non-delivery / short delivery of the Checked-In
Baggage.
5. In case of items of individual value equal to or more than US$ 100 contained within the Checked-In Baggage, proof of ownership in the form of
purchase bill (or any other proof to the satisfaction of the Assistance Service Provider).
In case of compensation from the Common Carrier having been received after payment of the claim by the Company hereunder, the Insured shall
repay to the Company such amount in excess of his / her loss after taking into account the amount of claim received from the Company and at that
received from the Common Carrier.
In case the undelivered Checked-In Baggage is subsequently traced by the Common Carrier and offered for delivery to the Insured, the Insured shall
take delivery of the Checked-In Baggage and refund the amount paid by the Company hereunder. In case of delivery of part of the Checked-In
Baggage, the amount paid by the Company attributable to such Checked-In Baggage shall be refunded by the Insured to the Company.
Documents to be submitted in support of the claim Checked-in Baggage Delay:
1. Property irregularity report stating the scheduled time of delivery and actual time of delivery of the Checked-In Baggage issued by the Common
Carrier;
2. Voucher of the Common Carrier for the compensation paid for the delay in delivery of the Checked-In Baggage;
3. Copies of correspondence exchanged, if any, with the Common Carrier in connection with the delay in delivery of the Checked-In Baggage.
4. PASSPORT LOSS
Please provide details of the incident leading to loss of passport i.e. when, where and how it happened: ______________________________
_________________________________________________________________________________________________________
Date and Place of loss: _________________________________________________________________________________________
Details of Police Report (please attach copy) : ________________________________________________________________________
Expenses incurred in obtaining new passport: ________________________________________________________________________
Sr. No. Details of Expenses Date Expenses in Foreign Currency
Total:
Documents to be submitted in support of the claim:
1. Police Report in original:
2. Details of the attempts made to trace the passport:
3. Statement of claim for the expenses incurred:
4. Receipt for payment of charges for obtaining an emergency certificate at the place of loss of the passport:
5. Receipt for charges for obtaining duplicate passport at the Country of Residence of the Insured.
In event the passport originally reported lost being traced and made available to the Insured, anytime before the emergency certificate at the place
of loss of the passport or the duplicate passport at the Country of Residence of the Insured is issued to the Insured, the Insured shall intimate the
concerned authorities forthwith and apply for the refund of the money paid with the application for emergency certificate or duplicate passport, as
the case may be. The Insured shall then refund to the Company such amount as has been refunded by the authorities.
5. PERSONAL LIABILITY
Date of Loss: Information Information_ Information/Information Information_ Information/Information Information_ Information_ Information_ Information Place of Loss: Information Information_ Information/Information Information_ Information/Information Information_ Information_ Information_ Information
Please provide details of injury / property damaged: ____________________________________________________________________
Name of aggrieved Third Party: ___________________________________________________________________________________
Amount of Liability: ___________________________________________________________________________________________
Documents to be submitted in support of the claim
1. Statement of claim furnishing particulars of the event leading to the liability
2. Photocopy of the police report wherever reported
D D M M Y Y Y Y D D M M Y Y Y Y
6. PERSONAL ACCIDENT & ACCIDENTAL DEATH (COMMON CARRIER)
Please state circumstances of accident i.e. how, when, where it took place: ________________________________________________
__________________________________________________________________________________________________________
Nature of Injury: ______________________________________________________________________________________________
State diagnosis and nature of treatment / surgery under taken: ____________________________________________________________
Provide name, address & telephone number of Hospital / Clinic: ____________________________________________________________
Treating Doctor's Name & Qualifications: ____________________________________________________________________________
Treating Doctor's Telephone Number: (O) InformationInformation_Information_Information_Information_Information_Information_Information_Information_Information_Information (M)InformationInformation_Information_Information_Information_Information_Information_Information_Information_Information_Information
Room / Ward / Bed Number: ______________________________________________________________________________________
Dates of treatment: FromInformation Information_ Information/Information Information_ Information/Information Information_ Information_ Information_ Information To: Information Information_ Information/Information Information_ Information/Information Information_ Information_ Information_ Information
Attending Doctor's Report
Date doctor contacted: Information Information_ Information/Information Information_ Information/Information Information_ Information_ Information_ Information Time:Information Information_ Information : Information Information_ Information
Nature of Ailment: ____________________________________________________________________________________________
State diagnosis and nature of treatment provided: _____________________________________________________________________
Describe any other disease or infirmity affecting present condition: ________________________________________________________
Was the accident due to Pregnancy: Information Information_ Information
Was the accident due to any pre-existing condition: Information Information_ Information
If yes, please give details:
Can the patient be evacuated back to the Republic of India? Information Information_ Information
Loss Incurred (Please tick):
Death
Permanent Total Disability: (Details)
Permanent Partial Disability: (Details)
Medical Doctor's Signature :____________________ Dated :____________________
Documents to be submitted in support of the claim:
1. Medical reports giving the details of the Accident, nature of Injury and the extent of disability.
2. In case of death of the Insured, death certificate issued by the Medical Practitioner who attended on the Insured.
3. Postmortem certificate to be produced if required by the Assistance Service Provider.
Police report in original in case the Accident shall have taken place in a public place or premises.
7. HIJACK DISTRESS ALLOWANCE
Name of Carrier: ___________________________________________________________________________________________
Port of Hijack: _____________________________________________________________________________________________
Port of Release: ____________________________________________________________________________________________
Dates & Time of Hijack: From: Information Information_ Information/Information Information_ Information/Information Information_ Information_ Information_ Information Time:Information Information_ Information : Information Information_ Information
Documents to be submitted in support of the claim:
Certificate of Hijack from the aircraft / ocean going vessels furnishing details of travel by the Insured, the fact of his / her being held captive
and confirmation of death, if death shall occur
8. EMERGENCY CASH ADVANCE ASSISTANCE
Date of Loss: Information Information_ Information/Information Information_ Information/Information Information_ Information_ Information_ Information
Reason and circumstances of Loss: _______________________________________________________________________________
Items lost and value of the same: _________________________________________________________________________________
I hereby declare that the above reason was the sole reason for the of my loss of travel funds. I also declare that there are no other sources of
funds available to me and the financial assistance required by me are needed on an urgent basis to prosecute the remainder of my trip. I have
made all efforts to recover my money unsuccessfully, and if I do secure my money at a future date, I shall repay to the Company the total
claim amount given to me.______________________________________________________________________________________
____________________________________________________________
SIGNED (Claimant or authorized person) Relationship with the Insured
Documents to be submitted in support of the claim:
Police report in original filed within 24 hrs of becoming aware of loss
9. HOME INSURANCE
Address of property where loss was sustained:
________________________________________________________________________
Date of Loss: Information Information_ Information/Information Information_ Information/Information Information_ Information_ Information_ Information
Cause of Loss: ________________________________________________________________________________________________
Exact description of nature of loss and it causes (in case of burglary, how was forceful entry gained into the premises and who is suspected
of the same):
Occupants of the premises at the time of loss / by whom it was discovered:
Has the loss been reported to the proper authorities? Please give details of where and to whom the loss has been reported along with the date and
time (If not reported, please give reasons for the same):
Details of any other insurance cover for the property:
Details of Loss Incurred:
D D M M Y Y Y Y
Sr. No. Items lost due to fire / burglary Amount
Documents to be submitted in support of the claim
1. First Information Report 4.Fire Brigade Report
2. Panchnama 5.Estimate and final bills of repairers
3. Investigation Report by the Police 6.Invoices of owned articles, if required by the Company
7. Legal opinion wherever required
8. The statement of claim furnishing the details of items lost and the values thereof duly supported by purchase bills wherever available. In the
event of the purchase bills not being available, he / she shall render such evidence as may be required by the surveyor for the latter to arrive at
the value of the lost items.
9. And any other document as may be appropriately applicable for the claims preferred under this section of the Policy.
Sr. No. Loss / Expenses Details Amount
Total:
Documents to be submitted in support of the claim:
1. In case of cancellation of the Trip either in the Country of Residence of the Insured or any other intermediate place forming part of the Trip by the
Common Carrier solely resulting from contingencies namely Earthquake, Storm, Flood, inundation, cyclone, tempest & Terrorism, duly
completed claims form to be accompanied by:
a. Confirmation of cancellation of the Trip from the Common Carrier detailing the circumstances of cancellation;
b. Original used air ticket indicating the cost the ticket and receipt for the refund of the fare of the Common Carrier towards the cancelled
portion of the Trip the cancellation charges retained;
c. Original bill and a receipt / letter obtained from the hotel and / or guest house and / or any other paid residential accommodation (available for
fee) indicating the amount paid for the accommodation, the refund given and the cancellation charges retained, wherever such
accommodation has be arranged at the place of cancellation of the Trip;
d. Used air ticket in original for return journey from the place of cancellation to the Country of Residence of the Insured which indicate the cost
of the tickets together with the receipts for the refunds obtained towards the unfulfilled portion of the Trip.
2. In case the cancellation of the Trip shall result because of personal contingencies covered hereunder or a decision taken at the instance of the
Insured arising out of the contingencies namely Earthquake, Storm, Flood, inundation, cyclone, tempest & Terrorism, the duly completed claims
form to be accompanied by:
a. Adeclaration from the Insured furnishing the circumstances that compelled him / her to cancel the Trip;
b. Medical evidence as may be required by the Assistance Service Provider in case of the cancellation of the Trip arising out of personal
contingencies of the Insured or his / her Immediate Family;
c. Receipt for the refund of the fare of the Common Carrier towards the cancelled portion of the Trip indicating the cancellation charges
retained;
d. Receipt / letter obtained from the for the hotel and / or guest house and / or any other residential accommodation (available for a fee)
indicating the cancellation charges retained, wherever such accommodation has be arranged at the place of cancellation of the Trip;
e. Used air ticket or boarding pass in original for return journey from the place of cancellation to the Country of Residence of the Insured
together with the receipts for the refunds obtained towards the unfulfilled portion of the Trip.
3. In case the cancellation charges either for the Trip or part of it or in relation to the accommodation in a hotel / guest house / other residential
accommodation is waived to the advantage of the Insured subsequent to any settlement of claim under this Benefit, the Insured shall forthwith
return the sum paid by the Company to the extent of such waiver.
10. TRIP CANCELLATION & INTERRUPTION
¨ Trip Cancelled / ¨ Trip interrupted / ¨ Also claiming for Trip Regained
Reason for Trip Cancellation / Interruption:____________________________________________________________________________
___________________________________________________________________________________________________________
Please detail out the above reason for trip cancellation / interruption (how, where, when and reason for the same):
Trip Cancellation / Interruption date: Information Information_ Information/Information Information_ Information/Information Information_ Information_ Information_ Information
Original Travel Dates:From: Information Information_ Information/Information Information_ Information/Information Information_ Information_ Information_ Information Time:Information Information_ Information : Information Information_ Information
Person Affected and Relationship with the Insured: (If not the Insured, please also provide address and contact details)
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Details of Losses / Expenses Incurred:
D D M M Y Y Y Y
D D M M Y Y Y Y H H M M
11. MISSED (FLIGHT) CONNECTION
Original Travel Schedule: (Please give date and time of all flights, mentioning the original and actual arrival and departure times. Please also
mention the name of carriers and flight numbers)
Which flight was delayed causing a missed connection? __________________________________________________________________
Reason for delay of the flight: _____________________________________________________________________________________
Details of expenses due to Missed Connection:
Sr. No. Expenses Amount
Documents to be submitted in support of the claim:
1. The confirmation from the Common Carrier of the delayed flight as to the expected time of arrival and the actual time of arrival at the port of delay
together with the reasons for delay.
2. Unused ticket for the ongoing flight (Missed Flight) with an endorsement of the Common Carrier of cancellation of the same.
3. Certificate from the Common Carrier of the Missed Flight that the fare for the part of the Trip covered by the Missed Flight is forfeited in full or in
part together with the amount of forfeiture.
4. Original used ticket obtained afresh towards the alternative flight for the part of the Trip covered by the Missed Flight indicating the amount paid
as fare.
In the event of the forfeited amount by the Common Carrier for the Missed Flight being refunded / returned to the Insured, subsequent to any
payment under this section, the Insured shall return the amount so refunded in full.
12. TRIP DELAY
Reason for Trip Delay: ___________________________________________________________________________________________
Please detail out the reason for trip delay (how, where, when, what was lost and reason for the same): _________________________________
Original Travel Dates:From: Information Information_ Information/Information Information_ Information/Information Information_ Information_ Information_ Information Time:Information Information_ Information : Information Information_ Information
Trip delayed on: Information Information_ Information/Information Information_ Information/Information Information_ Information_ Information_ Information
Person Affected and Relationship with the Insured: (If not the Insured, please also provide address and contact details)
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Details of Expenses Incurred:
D D M M Y Y Y Y H H M M
D D M M Y Y Y Y
Sr. No. Loss / Expenses Details Amount
Total:
Documents to be submitted in support of the claim:
In case of delay of the Trip either at the Country of Residence of the Insured or any other intermediate place forming part of the Trip by the Common
Carrier solely resulting from contingencies namely Earthquake, Storm, Flood, inundation, cyclone, tempest & Terrorism, duly completed claims form
to be accompanied by,
a. Confirmation of cancellation of the Trip from the Common Carrier detailing the circumstances of cancellation
b. Receipt for the refund of the fare of the Common Carrier towards the cancelled portion of the Trip indicating the cancellation charges retained
c. Receipt / letter obtained from the hotel and / or guest house and / or any other residential accommodation for a fee indicating the cancellation
charges retained by the agency, wherever such accommodation has be arranged at the place of cancellation of the Trip
d. Used air ticket or boarding pass in original for return journey from the place of cancellation to the Country of Residence of the Insured together
with the receipts for the refunds obtained towards the unfulfilled portion of the Trip (As any payment under this head shall be only in respect of
the difference between the actual charges incurred for the return journey from the place of cancellation to the country of residence and the
amounts obtained towards refund towards the unfulfilled portion of the Trip. These documents shall be submitted only in case there shall be an
additional expenditure incurred by the Insured)
In case the delay of the Trip shall result because of personal contingencies covered hereunder or a decision taken at the instance of the Insured
arising out of the contingencies namely Earthquake, Storm, Flood, inundation, cyclone, tempest & Terrorism, the duly completed claims form to
be accompanied by:
a. A declaration from the Insured furnishing the circumstances that compelled him / her to cancel the Trip
b. Medical evidence as may be required by the Assistance Service Provider in case of the cancellation of the Trip arising out of personal
contingencies of the Insured or his / her Family
Total:
Sr. No. Loss / Expenses Details Amount
Documents to be submitted in support of the claim:
1. A declaration from the Insured that he / she has strictly complied with the rules laid down by the Common Carrier or accommodation provider as
the case may be relating to the reconfirmation of the booking prior to the date of departure of the flight or occupation of the accommodation.
2. A confirmation from the Common Carrier of the bounced booking solely at their instance and responsibility.
3. A confirmation from the accommodation provider of the bounced booking solely at their instance and responsibility.
4. Insured shall lodge his / her claim on the Common Carrier and / or the accommodation provider as the case may be for the additional charges that
he / she might have incurred for which he / she has lodged a claim on this Company and in case of any recovery from the concerned agencies,
shall return such recovery to the Company to extent of amount paid hereunder.
c. Receipt for the refund of the fare of the Common Carrier towards the cancelled portion of the Trip indicating the cancellation charges retained
d. Receipt / letter obtained from the for the hotel and / or guest house and / or any other residential accommodation for a fee indicating the
cancellation charges retained by the agency, wherever such accommodation has be arranged at the place of cancellation of the Trip
e. Report filed with the Police having jurisdiction over the place of loss reporting the loss of the passport or travel documents and the application
made for a fresh passport / travel documents.
f. Declaration from the Insured that the passport / travel documents has been recovered / returned to him / her with the date of such recovery /
return or has not been recovered / returned or that alternative passport has not been obtained within the period for which the indemnity shall be
available under the policy.
g. Used air ticket or boarding pass in original for return journey from the place of cancellation to the Country of Residence of the Insured together
with the receipts for the refunds obtained towards the unfulfilled portion of the Trip (As any payment under this head shall be only in respect of
the difference between the actual charges incurred for the return journey from the place cancellation to the country of residence and the
amounts obtained towards refund towards the unfulfilled portion of the Trip. These documents shall be submitted only in case there shall be an
additional expenditure incurred by the Insured)
13. BOUNCED BOOKINGS- AIRLINES/ HOTELS
Reason for Bounced Booking: __________________________________________________________________________________
Please detail out the reason for the Bounced Booking (how, where, when, and reason for the same): ________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Original Travel / Accommodation Dates: From: Information Information_ Information/Information Information_ Information/Information Information_ Information_ Information_ Information Time:Information Information_ Information : Information Information_ Information
Days on which the booking was bounced: Information Information_ Information/Information Information_ Information/Information Information_ Information_ Information_ Information
Details of Expenses Incurred:
D D M M Y Y Y Y H H M M
D D M M Y Y Y Y
14. COMPASSIONATE VISIT
Person Hospitalised: ¨ Insured ¨ Family Member
Name of the person hospitalized (if not the Insured): _____________________________________________________________________
Relationship with the Insured: ____________________________________________________________________________________
Provide name, address & telephone number of Hospital / Clinic: ____________________________________________________________
Treating Doctor's Name & Qualiications: ____________________________________________________________________________
Treating Doctor's Telephone Number:(O) InformationInformation_Information_Information_Information_Information_Information_Information_Information_Information_Information (M)InformationInformation_Information_Information_Information_Information_Information_Information_Information_Information_Information
Room / Ward / Bed Number: InformationInformation_Information_Information_Information_Information_Information_Information_Information_Information_Information_Information_Information_Information_Information_Information_Information_Information_Information_Information_Information_Information_Information_Information_Information_Information_Information_Information_Information
Dates of hospitalisation:From Information Information_ Information/Information Information_ Information/Information Information_ Information_ Information_ Information Time:Information Information_ Information : Information Information_ Information
Date of onset of symptoms:Information Information_ Information/Information Information_ Information/Information Information_ Information_ Information_ Information
Sr. No. Loss / Expenses Details Amount
Total:
Documents to be submitted in support of the claim:
1. A certificate from the Medical Practitioner recommending the presence in the form of special assistance to be rendered by a member of the
Family or near relative during the entire period of Hospitalization. Certificate to also specify the minimum period of Hospitalization.
2. Discharge summary of the Hospital furnishing details - date of admission, date of discharge, and the presence of the member of the Family or
near relative on all days of Hospitalization.
3. Original ticket used for the travel to and fro by the member of the Family or near relative.
15. EMERGENCY HOTEL EXTENSION
Reason for Delay: ______________________________________________________________________________________________
Please detail out the above reason for Delay (how, where, when and reason for the same): __________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Delay date:Information Information_ Information/Information Information_ Information/Information Information_ Information_ Information_ Information
Original Travel Dates:From: Information Information_ Information/Information Information_ Information/Information Information_ Information_ Information_ Information Time:Information Information_ Information : Information Information_ Information
Person Affected and Relationship with the Insured: (If not the Insured, please also provide address and contact details) _____________________
___________________________________________________________________________________________________________
Details of Losses / Expenses Incurred:
Attending Doctor's Report
Date doctor contacted:Information Information_ Information/Information Information_ Information/Information Information_ Information_ Information_ Information Time:Information Information_ Information : Information Information_ Information
Nature of Ailment: ____________________________________________________________________________________________
State diagnosis and nature of treatment provided: _____________________________________________________________________
When did patient's symptoms first appear? _______________________________________________________________________
Describe any other disease or infirmity affecting present condition: _________________________________________________________
Was the ailment due to Pregnancy: Information Information_ Information
Was the ailment aggravated due to any pre-existing condition? Information Information_ Information
If yes, please give details:
Can the patient be evacuated back to the Republic of India? Information Information_ Information
Estimated time the patient would continue to be in the hospital? ___________________________________________________________
Is Medical Evacuation back to Republic of India needed? Please give detailed reasons of the ailment and reason for transportation:
Expenses Details
Sr. No. Loss / Expenses Details Amount
Total:
Date
Documents to be submitted in support of the claim:
1. Receipt for the amount paid to the hotel or guest house or any other accommodation provider for a fee for the charges per day paid towards
accommodation;
2. Evidence as may be required by the Assistance Service Provider in case the delay is caused by Earthquake, Floods resulting from unseasonal
rains, storm or cyclone or Terrorism;
3. Medical certificate furnishing details of date of admission and date of discharge together with the details of the Injury or Illness and the
treatment rendered, obtained from the Medical Practitioner in case of delay being caused because of Hospitalization of the Insured or Insured's
Family member or Traveling Companion resulting from any Injury or Illness to the Insured or Insured's Family member or Traveling Companion, as
the case may be;
4. In case of loss of passport, a copy of the first information report in relation to the complaint lodged with the police having jurisdiction over the
place of loss and a copy of the application lodged with the passport office for a duplicate passport;
5. In case of loss of travel documents, a copy of the report lodged with the Common Carrier for the loss of the travel documents and a confirmation
from the latter that the Insured could not undertake the travel as scheduled;
In case of delay solely attributable to Common Carrier and beyond the control of the Insured a confirmation by the Common Carrier of the said delay
having taken place at their instance together with a copy of the claim made on the Common Carrier for expenses incurred as a result of the delay.
16. LOSS OF BAGGAGE & PERSONAL EFFECTS
Date of Loss: Information Information_ Information/Information Information_ Information/Information Information_ Information_ Information_ Information
Reason and circumstances of Loss: : ________________________________________________________________________________
I hereby declare that the above reason was the sole reason for the Loss of my baggage & personal effects. I have made all efforts to recover my
baggage & personal effects unsuccessfully, and if I do secure my baggage & personal effects at a future date, I shall repay to the Company the total
claim amount given to me.________________________________________________________________________________________
SIGNED (Claimant or authorized person) Relationship with the Insured
____________________________________ ____________________________________
SIGNED (Claimant or authorized person) Relationship with the Insured
Details of Losses / Expenses Incurred:
D D M M Y Y Y Y
Sr. No. Loss / Expenses Details Amount
Total:
Details of compensation received:
Documents to be submitted in support of the claim:
1. Copies of the letter addressed to the Common Carrier, police authorities and hotel / guest house / accommodation provider with their
acknowledgment;
2. Copy of the first information report lodged with the police in relation to the complaint;
3. Reply if any in original received from the above referred authorities;
4. Evidence as may be required by the Assistance Service Provider for certification of the market value of the items lost whose individual value
shall have exceeded US$ 100.
17. RETURN OF MINOR CHILD/CHILDREN
In the Event of Hospitalisation
Person Hospitalised : ¨ Insured ¨ Family Member
Name of the person hospitalized (if not the Insured): ____________________________________________________________________
Relationship with the Insured: ____________________________________________________________________________________
Provide name, address & telephone number of Hospital / Clinic: ____________________________________________________________
Treating Doctor's Name & Qualifications:____________________________________________________________________________
Treating Doctor's Telephone Number:(O) InformationInformation_Information_Information_Information_Information_Information_Information_Information_Information_Information (M)InformationInformation_Information_Information_Information_Information_Information_Information_Information_Information_Information
Room / Ward / Bed Number: _____________________________________________________________________________________
Dates of hospitalisation:From Information Information_ Information/Information Information_ Information/Information Information_ Information_ Information_ Information Time:Information Information_ Information : Information Information_ Information
Date of onset of symptoms:Information Information_ Information/Information Information_ Information/Information Information_ Information_ Information_ Information
In Case of Death of the Insured
Cause / Circumstances of death: ___________________________________________________________________________________
Date of death of Insured: Information Information_ Information/Information Information_ Information/Information Information_ Information_ Information_ Information
Attending Doctor's Report
Date doctor contacted:Information Information_ Information/Information Information_ Information/Information Information_ Information_ Information_ Information Time:Information Information_ Information : Information Information_ Information
Nature of Ailment: ____________________________________________________________________________________________
State diagnosis and nature of treatment provided :_____________________________________________________________________
When did patient's symptoms first appear? _______________________________________________________________________
Describe any other disease or infirmity affecting present condition: ________________________________________________________
Was the ailment due to Pregnancy: Information Information_ Information
Was the ailment aggravated due to any pre-existing condition? Information Information_ Information
If yes, please give details:
Can the patient be evacuated back to the Republic of India? Information Information_ Information
Estimated time the patient would continue to be in the hospital? Information Information_ Information
Is Medical Evacuation back to Republic of India needed? Please give detailed reasons of the ailment and reason for transportation:
________________________________________________________________________________________________________
________________________________________________________________________________________________________

Expenses Details
Sr. No. Details of Expenses Date Expenses in Foreign Currency / INR
Total:
Documents to be submitted in support of the claim:
1. A certificate from the Medical Practitioner recommending the presence in the form of special assistance to be rendered by a member of the
Family or near relative during the entire period of Hospitalization. Certificate to also specify the minimum period of Hospitalization.
2. Discharge summary of the Hospital furnishing details – date of admission, date of discharge, and the presence of the member of the Family or
near relative on all days of Hospitalization.
3. Original ticket(s) used for the travel by the Minor Child(ren) back to the Country of Residence, if the ticket(s) are bought on behalf of the Insured
without any interference of the Company
4. Photocopy of the death certificate (wherever applicable) providing the details of the place, date and time, and the circumstances and cause of
the death (photocopy of the postmortem certificate wherever required by the Assistance Service Provider, for cases where postmortem is
conducted,), issued by the appropriate authority where the contingency has arisen.
18. POLITICAL RISK AND CATASTROPHE EVACUATION
Reason for Evacuation: __________________________________________________________________________________________
Please detail out the above reason for Evacuation (how, where, when and reason for the same): ______________________________________
____________________________________________________________________________________________________________
Evacuation date: Information Information_ Information/Information Information_ Information/Information Information_ Information_ Information_ Information
Original Travel Dates:From: Information Information_ Information/Information Information_ Information/Information Information_ Information_ Information_ Information Time:Information Information_ Information : Information Information_ Information
Details of Losses / Expenses Incurred:
D D M M Y Y Y Y
D D M M Y Y Y Y H H M M
Sr. No. Loss / Expenses Details Amount
Total:
Documents to be submitted in support of the claim:
1. Official Declaration by embassy of Country of Residence of the Insured
2. Original Invoice of Hotel Accomodation during the period Insured is unable to return to the Country of Residence
3. Original ticket(s) used for the travel back to the Country of Residence.
19. BAIL BOND
Name and contact details of the detaining authority:
The offense for which the insured is in custody:
Is this offense bailable as per the laws of the country? :
Please attach the court order stipulating the required amount as bail bond. Please attach more sheets to give details, if necessary.
20. SPONSOR PROTECTION
Name of the sponsor:
Cause of accident causing the demise of the sponsor: ____________________________________________________________________
Nature of injury causing the demise of the sponsor: ______________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Place of accident of the sponsor: ___________________________________________________________________________________
Name, address and telephone number of hospital / clinic where treatment was given to the sponsor: __________________________________
Name of treating doctor of the sponsor: ______________________________________________________________________________
Details of medical / surgical treatment given to sponsor: __________________________________________________________________
Dates on which the sponsor was given medical / surgical treatment: From:
To:
Please attach medical reports, doctor's statement giving the details of the sponsor and cause of death, and the death certificate of the sponsor.
Medical statements from relations / spouse will not be accepted. Please attach more sheets to give details, if necessary.
_____________________________________________________________________
_______________________________________________________________________
___________________________________________________________________________________________

21. STUDY INTERRUPTION
Due to hospitalisation of the insured
Name, address and telephone number of hospital / clinic where treatment is being given: __________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
_____________________________________________________________________
Name of treating doctor: _________________________________________________________________________________________
Details of ailment:______________________________________________________________________________________________
Cause of the ailment: …………………………………………………………………
Was the ailment / incident caused due to / aggravated due to a pre-existing condition? Please give details: ______________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Date of onset of ailment:
Nature of treatment : ___________________________________________________________________________________________
Dates of hospitalisation: From : To :
Reason for medical evacuation (if applicable): _________________________________________________________________________
Reason for not continuing studies abroad: ____________________________________________________________________________
Tuition fees paid in advance for the year:_____________________________________________________________________________
InformationInformationDue to death of sponsor or immediate family member
Name of the sponsor / immediate family member: ______________________________________________________________________
Cause of accident causing the demise of the sponsor / reason for death of immediate family member: _________________________________
Nature of accident causing the demise of the sponsor: ___________________________________________________________________
Place of accident of the sponsor: ___________________________________________________________________________________
Name, address and telephone number of hospital / clinic where treatment was given to the sponsor / the immediate family member: ___________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Name of treating doctor: ________________________________________________________________________________________
Details of medical / surgical treatment:______________________________________________________________________________
Dates of medical / surgical treatment: From :
To :
Reason for not continuing studies abroad: ____________________________________________________________________________
Tuition fees paid in advance for the year: _____________________________________________________________________________
Please attach medical reports, statements from the treating doctor and death certificate as proof of the above. Medical statements from relations or
spouse will not be accepted. Please also attach the receipts of the university fees paid. Please attach more sheets to give details, if necessary.
I/We hereby agree, affirm and declare that:
A. The statements/information given/stated by me/us in this claim form are true, correct and complete.
B. The details of all persons having an interest in the property in respect of which the claim is being made are provided as per the proposal form or by way of an endorsement in the policy. Furthermore, save and except as provided or disclosed in this claim form, no claim made here under (or the same/similar claim) has been made or lodged with any other insurance company.
C. No material information which is relevant to the processing of the claim or which in any manner has a bearing on the claim has been withheld or not disclosed.
D. If I/we have given/made any false or fraudulent statement/information, or suppressed or concealed or in any manner failed to disclose material information, the policy shall be void and that I / We shall not be entitled to all / any rights to recover there under in respect of any or all claims, past, present or future.
E. The receipt of this claim form/other supporting/related documents does not constitute or be deemed to constitute an agreement by the Company of the claim and the Company reserves the right to process or reject or require further/additional information and documents in respect of the claim.
F. I do hereby authorize International Subrogation Management (ISM) to inquire and obtain any information regarding my accident. Further, ICICI
Lombard is hereby authorized to release any and all information, including copies of pertinent documents, which ISM may deem necessary in
order to satisfy their inquiry, If during the investigation, ISM has identified a potential recovery source, allowing the Plan Participant's employer
to recover paid benefits, ISM is authorized to release any all records they deem necessary in order to pursue the recovery.
Dated : ________________ Place :____________________ Proposers Signature : ________________________________________
013080CF-SC
*Please read the policy wordings for detailed requirements of documents. ICICI Lombard General Insurance Company Ltd. Insurance is the subject matter of the solicitation MISC 29, 30, 50
Mailing Address: ICICI Lombard General Insurance Company Limited Interface Building No.11, 401/402 4th Floor, New Link Road Malad (W), Mumbai - 400064.
Corporate Address :ICICI Lombard General Insurance Company Limited, ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400 025.
Visit us at www.icicilombard.com Mail us at customersupport [at] icicilombard [dot] com
Now One Number for all your Insurance needs 1800 2666 (Toll Free also accessible from your mobile)
Insurance underwritten by ICICI Lombard General Insurance Co. Ltd. Insurance is the subject matter of solicitation. Misc 29, 50, 129.