Travel Insurance Claim Form - Loss Of Income - Budget Direct Travel Insurance
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4Travel Insurance Claim Form
Loss of Income
You must register any claim within 30 days of completion of your travel. Please supply original documents of the evidence you intend to rely on for
your claim, and send by registered post to ensure delivery.
Claimant Details
Claim Reference
(if known)
Title (Mr / Mrs etc)
First Name
Surname
Date of Birth
/
/
Nationality
Occupation
Medicare Number
Parent / Guardian’s Medicare Number
(If medical claim is for a minor)
Home Address
Home Phone
Work Phone
Mobile
State
Postcode
Email
Policy Details
/
/
Policy Number
Date Issued
Number of Travellers
Independent Travel Arrangements:
Yes
No
If no, provide the following*:
*Travel Agent and Branch
*Tour Operator
Date of Booking
Departure Date
Return Date
Total Days
/
/
/
/
/
/
Country
Resort / Town
GST
(for domestic policy claims only)
Are you registered for GST and did you claim a
If yes, what is your input tax credit entitlement percentage:
Yes
No
GST input tax credit on your premium?
(i.e. a full entitlement is 100%)
It is against the law to submit a fraudulent insurance claim. If your claim is
For medical related claims:
found to be fraudulent, the claim will be declined and Insurers will pursue
4. I authorise any doctor, hospital, travel insurer or other organisation or person
recovery through the use of legal action.
having any records or information concerning my medical history or treatment
to furnish such records or information as may be requested by Auto & General
1. I / We hereby declare that all information, answers, and documents given
Insurance Company Limited or their agents. I understand that in executing this
in connection with this claim are true and correct to the best of my / our
authorisation, I waive the right for such information / records to be privileged. I
knowledge and belief. I / We have not omitted any material information,
am also aware that such information / records are relevant in the evaluation of
which would affect the Underwriters judgement of the claim. I confirm
my claim and that non-submission could prejudice my claim. A photocopy of this
that where a claim or claims are made on behalf of others, I have their full
authorisation shall be considered as effective and valid as the original.
authority to act on their behalf, and I confirm that I understand that Auto
Privacy Statement
& General Insurance Company Limited will not accept responsibility if any
The personal and sensitive information collected in this form, and other information you
payments are not distributed proportionately to the persons concerned.
or third parties provide in connection with this claim will be held, used and disclosed
2. I / We understand that the information on this form will be passed to or
by us to process this claim, compile and analyse data, and resolve claim disputes.
used by Auto & General Insurance Company Limited for my insurance, this
We may have to disclose your personal and other information to third parties who
includes underwriting, processing, handling claims and preventing fraud
assist us in assessing and processing this claim, including other insurers, health
and could include passing details to agents or other insurers. This includes
providers, investigators, our specialist advisors, service providers, or as required by
access to my previous claims with other insurers.
law. Your personal information may also be disclosed to third parties in the countries
3. I / We assign all rights to Auto & General Insurance Company Limited
and regions nominated under your policy, or any other regions where you may
and consent to them seeking reimbursement of any medical expenses
require assistance. For further information please see our privacy policy or email
paid by them.
us at .au.
I have read and fully understand the declarations above (ALL persons claiming must sign)
Claimant’s Name
Signature
Date of Birth
Date
/
/
/
/
Claimant’s Name
Signature
Date of Birth
Date
/
/
/
/
Please return this claim form to:
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Budget Direct Travel Insurance, PO Box 547, Pyrmont NSW 2009
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