Travel Insurance Claim Form
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1
2TRAVEL INSURANCE CLAIM FORM
Postal Address
：
Claims Hotline: 400-650-0017
14F Air China Plaza 36 Xiaoyun Road,
Fax: 010-8447-5981
Chaoyang District Beijing 100027, P.R.China
Email: .cn
In order for your claim to be dealt with promptly, please ensure ALL RELEVANT SECTIONS of this Claim Form are fully completed and returned
to us by post together with all the required claims evidence. A separate claim form must be completed for each Insured Person who is claiming
under the policy.
Please use BLOCK letters. Please retain a copy of all documents sent to us for your records.
Please note all expenses incurred in completing this claim form and providing all the necessary evidence to support this claim must be paid by
you. Expenses incurred in providing evidence or translations are not covered under this policy.
SECTION 1 – INSURED DETAILS
Claim NO:
1. Policy Number:
□□□□□□□□□□□□
(Mondial Use Only
)
2. Name of insured person:
ID number
：
3. Date of birth:
/
/
Occupation:
4. Address of claimant to be used for correspondence:
Code:
5. Tel (Home/ Work):
Tel (Mobile):
Email:
6. Date travel arrangements booked:
/
/
Date of departure:
/
/
Date of return:
/
/
7. Have you made any previous claims in respect to travel insurance
？
YES
NO
□
□
If yes, please provide exact details of claim/s (date/amount/type of claim/insurance company involved):
8. Are you able to claim through any other source?
YES
NO
□
□
If yes, please provide information:
SECTION 2 – MEDICAL EXPENSE CLAIM
1. Date of Incident:
/
/
Time (am / pm):
Location (City / Country):
2. Please advise (in detail) the nature of the illness contracted or injury sustained for which this claim is related:
3. Have you ever been hospitalized or advised to be hospitalized? YES
NO
If yes, please fill in the table below:
□
□
Admission
Discharge
NO. of
Hospitals Name
Diagnosis
Treatment/Medication
Date
Date
Hospitalization
4. Have you ever suffered from any disorder which required that a) received more than 7 days treatment b) were off
work/study for more than one week c) had specialized treatment (i.e. chem/radiotherapy and dialyse, etc.)?
YES
NO
If yes, please describe the details:
□
□
5. Are you currently on treatment/medication or advised to have treatment? YES
NO
□
□
If yes, please describe the treatment/medication.
6. Please provide details of the treatment provided overseas
：
Name of hospital/clinic
Address
：
：
Name of treating doctor
Specifics of the treatment
：
：
7. Has the illness or injury mentioned above occurred previously (prior to this specific incident)? YES
NO
□
□
If yes, please provide details (date/location/previous treatment)
8. Please itemize all medical expenses that you are seeking reimbursement for
：
Explanation of the Expense
Name of Hospital/Doctor
Currency
Amount Claimed
TOTAL OF MEDICAL EXPENSES BEING CLAIMED
： ： ： ：
Allianz China Life International Travel Insurance
Page 1of 2
2009-2010 Claim Form
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