Fillable Medical Certificate-Travel Insurance Claim Form printable pdf download

Travel Insurance Claim Form

Medical Certificate

This must be completed by the Registered General Practitioner (GP) of the person whose illness / injury / death has given rise to the claim. Any charge made for the completion

of this certificate is the responsibility of the insured and is not refundable under the insurance policy. Please ensure the GP answers all relevant questions. Ticks, dashes, N/A

etc will not be acceptable. This information will be treated as private and confidential. A certificate not containing the specific information requested will not normally suffice.

Full name of patient

Date of Birth

Are you the regular medical attendant / from the same practice:

Yes

If yes, for how long

If no, what is your involvement with this matter

State precise nature of the medical condition / illness / injury / cause of death, that gives rise to this claim

If injury, state how this was caused

If claim is result of pregnancy: Date pregnancy confirmed

LMP

EDC

Has patient suffered from the same or related condition in the past five years:

Yes

If yes, for how long

State the exact date of onset of symptoms of conditions

Date first consulted

Date of any serious deterioration / exacerbation, if applicable

What ongoing medical condition(s), or medical complication directly attributable to the condition(s), were being investigated by a registered medical

practitioner at:

Date trip insurance was purchased

Date trip was booked

Is the illness / injury attributable to drugs, alcohol or HIV or HIV related illness, including AIDS: Yes

Give Details

Has the person named above received a terminal prognosis: Yes

If yes, what date was the terminal prognosis given to:

The patient

The claimant

(if not the same person)

Has the patient been referred to or seen by a hospital doctor or surgeon or needed inpatient treatment for this or any related condition within 12 months

prior to the date the trip insurance was purchased? If so, please give full details including dates:

If the patient was booked to travel did they consult you prior to booking or travelling regarding the advisability of undertaking the holiday or journey:

Yes

If yes, on what date

If no, when would you have advised cancellation had you been aware of the planned trip

If the patient travelled, were they fit to travel the date of departure

Provide details of patient’s state of health at the time the insurance was purchased and date of booking the trip

State exact reason for cancellation

Please advise the date when it first became apparent that the holiday should be cancelled

Please state the exact date you advised the need to cancel

Are you prepared to certify that, soley due to the condition described above, the claimants are compelled to cancel their holiday arrangements:

Yes

To be completed by the usual Registered General Practitioner (GP): I have examined the patient and / or referred his / her medical records

and I declare that the information given is correct and that no details relevant to the case have been omitted.

Surgery

Name

Qualifications

Stamp

Date

Sign

Please return this claim form to: Budget Direct Travel Insurance, PO Box 547, Pyrmont NSW 2009

Medical Certificate-Travel Insurance Claim Form

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