Travel Insurance Claim Form - Loss Of Income - Budget Direct Travel Insurance Page 3
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4Travel Insurance Claim Form | Loss of Income
Details of Absences as a Result of The Accident
On what dates was the employee absent from work due to the accident
Work time lost (weeks / days / hours)
Date From
Date To
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Has the employee returned to work:
Yes
No
If no, will the position be held open:
Yes
No
If payments have been made give details below (eg sick pay, workers compensation)
Details of payment / amount
Details of person completing this form
(Employer or Accountant)
Name
Position in business
Home Phone
Mobile
Work Phone
Email
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Signature
Date
Bank Details of Claimant
Should Auto & General Insurance Company Limited need to reimburse you we require your bank details.
Name of Account Holder
BSB
Account Number
Additional space to continue any questions necessary
Please return this claim form to:
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Budget Direct Travel Insurance, PO Box 547, Pyrmont NSW 2009
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Parent category: Business