Travel Insurance claIm Form

1 traveller dETAiLsLoss oR ThEfT of cAsh13 Please print your details clearly in cAPiTAL letters using a pencAncELLATion oR chAngEs To Travel /AddiTionAL ExPEnsEs 2 Please provide all original receipts, tickets relating to expenses, and doctor/hospital certificates relating to injured or ill person for changes to Travel supplementary pages as the changes to Travel plans were due to medical reason; injury or illness: Travel cancellation ExpensesAmount Paid (nZ$)date PaidAmount Refunded (nZ$)deposit for package holidayBalance for package holidayTravel TicketsAccommodation costsother costs (please specify)TotalnZ$nZ$name, address, and phone number of Persons usual doctordetails of injury of illnessAmount claimedJourneydestination sType of ticket heldbefore nZ departureone-wayReturnAddressAgedate loss notifiedWhich Police station was advised?

2 Police Report detailsname of PersonAffecting your TravelRelationship to youdate of lossdate and time ofactual departureReason fortravel delayAirline & flight numberfor Travel delaysReason for TravelLeisureBusinessotherhas the Person ever suffered from this or a similar condition before?date of accident or date illness startedYesno//////$details of loss incidentReason for cancelling or changing your travelWere alternative arrangements sought?Yesnodetails ofarrangementdate of incidentdate bookings were cancelledWho advised you not to Travel ?////Total number of days of journeyfrom//To//name of traveller (Mr/Mrs/Ms/Miss)Addressoccupati ondate of Birth//Telephonehome/workMobile Email( )( ) Travel Insurance claIm form Policy numbername of Policy ownercountryPlace of lossFor oFFIce use onlYDaTe reQuesTeD:DaTe senT:DaTe receIveD:06/14cig6041 Type of injury or illnessname and addressof family doctorname and detailsof Rental companydid you contact our emergency assistance provider Was the incident reported to police?

3 Name of Police stationPolice Reportnumberhas the claimant ever suffered from this or a similar illness or injuryhas the claimant lodged a claIm with Acc?Please give full details of theaccident or illnessdetails or other treatment by doctor, dentist, and/or hospitalPlace of incidentTown/cityclaimant namecountryMEdicAL And dEnTAL ExPEnsEs4 Please provide all original doctors/hospital accounts, hospital discharge letter and/or medical reports, receipts/statements from private health of accident or date illness startedRelationship to policy owner//////////date of first medical or dental consultationdate of hospital admissiondate of incidentdetail of damagedetails of incidentPlace ofincidentcountrydate of hospital dischargename of doctor/dentist and hospitalYesYesYesYesnonononoMedical Expensesname of medical providerType of medical expensedate of dischargeAmount (local currency)Amount (nZd)

4 Paid in full? Dr H smith, Fairview 10/10 eur $ YesREnTAL VEhicLE ExcEss5 Rental Vehicle ExpensesdesciptionAmount Paid (nZ$)date PaidAmount Refunded (nZ$)Excess paid to rental companyTowing/Vehicle return costsOther costs (please specify)date of Birth//06/14cig6042details of complaintname and details of affected partydetails of incidentdetails of party claiming against youRelationship to affected partyWere items coveredby other Insurance ? did you own allmissing items?did you admitliability?Were items lost by carrier ( Airline)have you reportedloss to the carrierhave you lodged a complaint for loss/damage?PiR or claIm noReasons for liabilityPlease give full details of eventWhat actions weretaken to recover items?LuggAgE And PERsonAL EffEcTs6 Where were you when the loss, damage, or theft occured?

5 ////date of Loss or damageAuthority reported toname of insurancecompanyif not, who was the owner of the items?datereportedname of carrierYesYesYesYesYesYesnonononononoPER sonAL LiABiLiTY7 Please provide all details including letters or demands of a claIm made on of incidentPlace ofincidentcountryPlace of incidentTown/cityclaimant namecountryRelationship to policy ownerdate of Birth//The Montreal convention imposes a liability on Airlines. Ensure you report your incident immediately to the airline and obtain a Property irregularity Report (PiR).details of lost items and purchase list for baggage delayitem description (Make and Model)owners initialsdate of purchasename and address of supplier for claimed itemsoriginal Purchase price nZ$Amount claimed nZ$* Please note all items may be subject to Travel claIm form has been completed.

6 The declaration section has been have provided your bank account details in the Payment details in a foreign language have been translated into English at your have provided all the specified documents with your claIm . Refer to the documents Required section for a full list of documents. Please note: we reserve the right to request further documents to be submitted that may support your claIm form and ALL supporting documents may be mailed to us at Box 24031 Wellington 6142, faxed to (04) 470 9151, or emailed to if you have any questions or need help filling in this form , please call us on 0800 660 150, we re available from to Monday to detailsclaim proceeds will be credited directly into your bank account. direct crediting enables almost immediate access to funds and removes the risk associated with mailing cheques, clearance delays and mail problems.

7 Please note: we cannot deposit into a credit card bank account details below:Bank account name:declarationThe information supplied is true and correct and i have not withheld any information that is relevant to this claIm . in respect of an Accident or illness claIm , i request and authorise any hospital doctor or other person who had attended or examined me to provide to cigna Life Insurance nZ Ltd or its representative any and all information concerning any illness or injury suffered, medical history, consultations, prescriptions or treatments and all hospital or medical records that may be included as part of the proofs of the claIm submitted. A photocopy of this authorisation will be considered as effective and valid as the authorise the disclosure to cigna Life Insurance nZ Ltd personal information held by any other person or organisation regarding or affecting this claIm and authorise cigna Life Insurance nZ Ltd to release information regarding or affecting this claIm to any person or organisation, including other members of the Insurance industry, for claims, underwriting or industry : date: / /The personal information collected on this claIm form will be held by Cigna Insurance NZ Ltd and you have certain rights of access to and correction of this information under the Privacy Act 1993To FacIlITaTe PromPT assessmenT oF Your claIm Please ensure THaT.

8 806/14cig6044 Documents required for all claimsThe completed Travel claIm form including sections for traveller details, Payment details and signed Travel itinerary showing new Zealand departure and return of Travel claimscomplete the cancellation or changes to Travel /Additional Expenses section of the Travel claIm evidence for the cause of the change to your Travel evidence for costs incurred, invoices or credit card statements, and any refunds your Travel was booked through a Travel agent, a letter from the agent detailing amounts paid and refunds cancellation was due to medical reasons please provide completed Medical Attendants statement. if cancellation was due to death please provide a certified copy of the death of Personal money claimscomplete the Personal Money section of the Travel claIm evidence for the amount of loss and a copy of the police and Dental claimscomplete the Medical and dental section of the Travel claIm all hospital and/or specialist Reports, including hospital discharge all Medical Bills and statements from your private health insurer and/or Acc details.

9 Rental vehicle excess claimscomplete the Rental Vehicle Excess section of the Travel claIm the Rental Vehicle agreement, and car Accident evidence of any additional costs and Personal effects claimscomplete the Luggage and Personal Effects section of the Travel claIm evidence that you reported the loss to the Authorities, police reports, airline evidence of ownership, photos, evidence of purchase of the evidence of any compensation damaged, include repairs Delay claimscomplete the Luggage and Personal Effects section of the Travel claIm the lost baggage report from the Airline ( PiR).include evidence of emergency items that you may have evidence of any compensation received from the Delay claimscomplete the cancellation or changes to Travel /Additional Expenses section of the Travel claIm the delay report from the Airline (showing delay time and reasons), Air Tickets, and Boarding evidence of any additional costs incurred by the liability claimscomplete the Personal Liability section of the Travel claIm all correspondence with third parties that are making a claIm against reports of police or other authorities, where a report has been required for Travel claims9 Please note: We may need other documents from you to support your claIm .