Collinson Medical Claim Form 1234 Consent(Required) I confirm that all information I provide will be true and accurate as I understand the information provided will form part of my claim submission.Claimants InformationName(Required) First Last Title(Required)MrMrsMsMissOtherAddress(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of Birth(Required) DD slash MM slash YYYY Occupation(Required) Home Telephone NumberMobile Telephone Number(Required)Email(Required) Enter Email Confirm Email Reason for Trip(Required) Business Leisure Policy DetailsCertificate Number(Required) Issue Date(Required) DD slash MM slash YYYY Start Date(Required) DD slash MM slash YYYY End Date(Required) DD slash MM slash YYYY Country of Destination(Required) Date Trip Booked(Required) DD slash MM slash YYYY Departure Date(Required) DD slash MM slash YYYY Return Date(Required) MM slash DD slash YYYY Other ClaimantsNameCertificate NumberDate of BirthAddress (if different from above) Add RemoveOther Insurance (Travel, complimentary with your bank / credit card, home insurance, etc)Type of PolicyName of InsurerContact NumberPolicy Number Add RemovePlease provide details of any other claim made with other Insurers for this incidentName of InsurerTelephone NumberClaim Reference Number Add RemoveHave you made a travel claim in the last 3 years? If yes, please provide the followingName of InsurerType of claimContact NumberPolicy Number Add Remove About your claim Have you already notified our Medical Operations team of this incident? Please provide the date and time and Case Reference Number if applicable Date DD slash MM slash YYYY Time Hours : Minutes AM PM AM/PM Case Reference Number If you did not notify our Medical Operations team, please confirm the reason whyCircumstances leading to the Medical Expenses being claimed(Required)If claiming due to an injury, please confirm the exact location of the accident and activity taking place at the timeThe date symptoms first began(Required) DD slash MM slash YYYY The time symptoms first began(Required) Hours : Minutes AM PM AM/PM The date you first sought medical attention(Required) DD slash MM slash YYYY The time you first sought medical attention(Required) Hours : Minutes AM PM AM/PM Details of the facilities where treatment was obtained, to include the name, address, contact telephone number and email address(Required)If you were admitted to hospital please confirm your admittance and discharge dates Costs Being ClaimedDescriptionDate of TreatmentName of FacilityCostCurrencyPaid Y/N YesNo Add RemoveHave you suffered from a similar condition in the past, please provide detailsDetails of any 3rd person involved in the incident giving rise to the claimNameAddressName of InsurerPolicy Number Add RemoveDid you incur/lose any costs following your illness, please provide detailsCosts Being ClaimedDescriptionDateCostCurrency Add RemoveIf you feel there is any further information to add please detail below Settlement DetailsName of Account Holder(Required) Name of Bank(Required) Account Number Sort-Code SWIFT / BIC (If Non-UK Account ) IBAN (If Non-UK Account ) Please tick the box to confirm you agree with the Declaration StatementDeclaration(Required) I agree Submit Claim InformationPlease upload the following documents to substantiate your claim Evidence of your pre-booked outward and return journeys from and to the UK. This may take the form of a confirmation of booking invoice, travel itinerary or boarding passes. In the event that this information was sent to you via email, a copy of the email and any attachments will suffice. This information is required to ensure that your trip dates fall within the period of insurance. Receipts and Invoices for the expenses and any additional costs. Medical Report from the treating facility confirming the symptoms, treatment and diagnosis. Bank statements confirming the payment made for costs detailing the rate of exchange applicable. Booking invoices and cancellation invoices in respect of any lost expenses you have incurred. Medicare details if your costs were incurred in Australia and you registered for Medicare. If claiming for costs incurred in an EHIC Reciprocal country please complete the attached declaration and return with all original documents by recorded delivery to the following address: Collinson Assistance Services Ltd, Sussex House, Perrymount Road, Haywards Heath, West Sussex, RH16 1DN Files Drop files here or Select files Max. file size: 25 MB. Consent I understand the following Submitting my claim does not confirm cover and my claim will be assessed in accordance with the policy terms and conditions. I need to retain all original documentation until my claim is settled. Upon receipt of the claim additional information/documentation may be required to validate my claim. There may be excesses of £50/£250 applicable per section (as per my policy schedule) that will be deducted from any payment made. There are limits applicable to my policy as detailed in my policy schedule. I should receive a response within the next 10 days. CAPTCHA
