Collinson Medical Claim Form

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 Information

Name(Required)

First Last

Title(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth(Required)

Occupation(Required)

Home Telephone Number

Mobile Telephone Number(Required)

Email(Required)

Enter Email Confirm Email

Reason for Trip(Required)

Business

Leisure

Policy Details

Certificate Number(Required)

Issue Date(Required)

Start Date(Required)

End Date(Required)

Country of Destination(Required)

Date Trip Booked(Required)

Departure Date(Required)

Return Date(Required)

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)

Type of Policy

Name of Insurer

Contact Number

Policy Number

Please provide details of any other claim made with other Insurers for this incident

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

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

Time

Case Reference Number

If you did not notify our Medical Operations team, please confirm the reason why

Circumstances 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 time

The date symptoms first began(Required)

The time symptoms first began(Required)

The date you first sought medical attention(Required)

The time you first sought medical attention(Required)

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 Claimed

Description

Date of Treatment

Name of Facility

Cost

Currency

Paid Y/N

Have you suffered from a similar condition in the past, please provide details

Details of any 3rd person involved in the incident giving rise to the claim

Name

Address

Name of Insurer

Policy Number

Did you incur/lose any costs following your illness, please provide details

Costs Being Claimed

Description

Date

Cost

Currency

If you feel there is any further information to add please detail below

Settlement Details

Name 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 Statement

Declaration(Required)

I agree

Submit Claim Information

Please 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

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.

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