Travel Insurance Claim
Travel Insurance Claim
1. Policyholder Information
This section contains the personal details of the policyholder.
|
Full Name |
[Your Name] |
|---|---|
|
Policy Number |
123456789 |
|
Email Address |
[Your Email] |
2. Trip Details
This section provides information about the trip.
|
Destination |
Paris, France |
|---|---|
|
Travel Dates |
2023-10-01 to 2023-10-15 |
|
Purpose of Travel |
Leisure |
3. Claim Details
This section outlines the specifics of the claim being made.
|
Claim Type |
Medical Expenses |
|---|---|
|
Incident Date |
2053-10-10 |
|
Claim Amount |
$2,000 |
|
Incident Description |
I suffered a severe allergic reaction and had to be hospitalized. |
4. Supporting Documents
list of supporting documents attached with the claim.
-
Copy of Passport
-
Medical Bills and Receipts
-
Doctor's Report
-
Proof of Travel (Boarding Pass)
5. Policyholder Declaration
I hereby declare that the information provided is true and correct, to the best of my knowledge. I understand that any false or misleading information could result in the rejection of my claim.
Name: Maricar David
Date: [DATE SIGNED]
