Travel Insurance Claim Form Page 2
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1
2TRAVEL INSURANCE CLAIM FORM
SECTION3–DAILY INPATIENT CASH SUBSIDY CLAIM
1. Admission Date:
/
/
2. Discharge Date:
/
/
3. Duration of Hospitalization:
SECTION 4 –ACCOMPANYING ON THE INPATIENT OF DEPENDENT CHILDREN CLAIM
1. Information of the inpatient of dependent children:
Country
Name of Hospital
Admission Date
Discharge Date
Diagnosis
2. Is it recommended by qualified doctors?
YES
NO
□
□
3. Your accompanying expenses (Up to 5 Days). Currency:
st
nd
rd
th
th
1
day
2
day
3
day
4
day
5
day
Total
SECTION 5 – TRAVEL DELAY CLAIM
.
1. Scheduled Date of arrival
：
/
/
Scheduled Time of Arrival (am/pm)
：
/
/
Actual Date of arrival
/
/
Actual Time of Arrival (am/pm)
/
/
：
：
2. Please advise the flight/train number
：
3. Please provide the reason given (by the transport representative) for the delay
：
SECTION 6 – ADDITIONAL INFORMATION OR COMMENTS TO SUPPORT YOUR CLAIM
If you are claiming under a section of the policy not provided for on this claim form, please provide details below:
We recommend that you contact us for advice on the documents required to support your claim.
SECTION 7 – PAYMENT DETAILS AND CLAIM PAYMENT DECLARATION
Please indicate your information of bank transfer
（ （ （ （
C hina Post is not supported
） ） ） ）
. Note that no claims will
be settled in cash.
Name of Bank and Branch(Please give the detailed city information)
：
Account Name
Account No
：
：
If the payee differs from the claimant in Section 1, please provide the following details (if not, leave blank).
Name of Payee
Address of Payee
Code
：
：
：
Tel
Passport/ID Number
Relationship with Claimant
：
：
：
Please read the following declaration carefully and sign & date below:
I (the Claimant) declare that all statements and particulars contained on this claim form are true and correct.
I (the Claimant) acknowledge and authorize that the underwriter or its agent may give to and obtain from other
insurers and / or other authorities, personal information relating to this claim.
I (the Claimant) authorize the insurer or its agent to get related information and documents in respect to this claim
from any other persons, police offices, hospitals, etc.
/
/
Signature of Claimant
：
Date
：
Allianz China Life International Travel Insurance
Page 2of 2
2009-2010 Claim Form
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