Collinson Cancellation Claim Form

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Consent(Required)

Claimants Information

Name(Required)
Address(Required)
DD slash MM slash YYYY
Email(Required)
Reason for Trip(Required)

Policy Details

DD slash MM slash YYYY
DD slash MM slash YYYY
DD slash MM slash YYYY
DD slash MM slash YYYY
DD slash MM slash YYYY
DD slash MM slash YYYY
Other Claimants
Name
Certificate Number
Date of Birth
Address (if different from above)
 
Other Insurance (Travel, complimentary with your bank / credit card, home insurance, etc)(Required)
Type of Policy
Name of Insurer
Contact Number
Policy Number
 
Please provide details of any other claim made with other Insurers for this incident(Required)
Name of Insurer
Telephone Number
Claim Reference Number
 
Have you made a travel claim in the last 3 years? If yes, please provide the following
Name of Insurer
Type of claim
Contact Number
Policy Number