Transcription of Trip Claim Form
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Trip Claim Form
TRIP Claim FORM - TIS - 06/2020 Trip Claim Form Step 1 - Choose The Type Of ClaimTrip Cancellation I am unable to leave on my trip due to an unforeseen event and want to request reimbursement for non-refundable trip payments and deposits. I had an unforeseen delay that caused me to have additional out-of-pocket expenses such as unplanned hotelTrip Delay accommodations, meals, and local transportation. I had an unforeseen interruption that caused me to have unused, non-refundable portions of my trip and/orTrip Interruption caused me to purchase new or additional airline, bus, or train 2 - Provide Documentation (provide all)Provide the following required documentation: Provide copies or photos of your itinerary and paid invoice.
diagnosis list, medication list, physician dictation, office notes, physical therapy records, occupational therapy records, pathology reports, cytology reports and the results of all laboratory tests. Send to: Berkshire Hathaway Specialty Insurance Company P.O. Box 2986 Clinton, IA 52733-2986 Telephone: 855.205-6054 Fax: 715.303.6328
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