battleface claim form 1Personal Information2Claim Information3Consent Policy Number Name* First Last Email* Contact number* Address* 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 Are you filing this claim on behalf of someone?* Yes No Claimant name* First Last Claim type*MedicalBaggageEquipmentTrip CancellationTrip InterruptionAll other What happened?*When did it happen?* MM slash DD slash YYYY When did you seek medical treatment?* MM slash DD slash YYYY Where did you receive medical treatment?* Were you admitted to a hospital?* Yes No Admission Date* MM slash DD slash YYYY Discharge Date* MM slash DD slash YYYY How did you pay for these expenses (cash, credit card, bank wire, and etc)* What currency these expenses were paid in?* Total amount filed for reimbursement:* CurrencyAmount*AmountAttach supporting documents:Medical report, Invoices, Receipts Drop files here or Select files Max. file size: 25 MB. Any additional informationWhat happened?*When did it happen?* MM slash DD slash YYYY What time did it happen?*01:00h02:00h03:00h04:00h05:00h06:00h07:00h08:00h09:00h10:00h11:00h12:00h13:00h14:00h15:00h17:00h18:00h19:00h20:00h21:00h22:00h23:00h24:00hWhere did it happen?* Device(s) being claimed:* When did you purchase these device(s):* Did you file a police report or a complaint?* Yes No Total amount filed for reimbursement:* CurrencyAmount*AmountAttach supporting documents:Original purchase receipt, copy of your police report or complaint, any other documents Drop files here or Select files Max. file size: 25 MB. Any additional informationWhat happened?*LostDamagedStolenWhen did it happen?* MM slash DD slash YYYY Please add flight information here*ToFromDate of travelAirline Record Locator NumberE-ticket Number Did you file a Property Irregularity Report with an airline?* Yes No Did you purchase any items?* Yes No Total amount filed for reimbursement:* CurrencyAmount*AmountAttach supporting documents:Airline property irregularity report, police report or complaint, any receipts, any other documents Drop files here or Select files Max. file size: 25 MB. Any additional informationWhat happened?*When did it happen?* MM slash DD slash YYYY Did you cancel your prepaid reservations with your airline, hotel travel agency or tour operator?* Yes No When* MM slash DD slash YYYY In order for us to process your claim and cancellation must be placed with your airline, hotel travel agency or tour operator first. When contacting your booking agency please obtain a copy of all supporting documentation such refund confirmationTotal amount filed for reimbursement:* CurrencyAmount*AmountAttach supporting documents:Original itinerary and travel booking confirmations, proof of reason for cancellation: i.e. medical report, or police report, cancellation and refund confirmation from your airline, hotel travel agency or tour operator, any other documents Drop files here or Select files Max. file size: 25 MB. Any additional informationWhat happened?*When did it happen?* MM slash DD slash YYYY Where did it happen?* Total amount filed for reimbursement:* CurrencyAmount*AmountAttach any other supporting documents, reports and receipts here Drop files here or Select files Max. file size: 25 MB. Any additional information first tick box* I / We confirm that the information provided in this form and in any accompanying supporting documentation is true, accurate and complete to the best of all claimants’ knowledge. In the event of false, inaccurate or incomplete information being provided the Insurer reserves the right to cancel your policy and reject your claim in full or part.*first tick box* I / We give authority to battleface (as agent of the relevant underwriter) and their appointed representatives to approach any third party who holds information relating to the incident giving rise to this claim, including, but not limited to medical practitioners and hospitals/clinics where the claim relates to a medical condition or injury. Such authority will permit the third party(ies) to release relevant information to battleface to assist in the investigation and resolution of this claim.*first tick box* I / We hereby grant battleface full rights of subrogation in respect of any payments made on behalf of all claimants.*first tick box* I / We further agree to fully co-operate with any such recovery efforts from liable third party or parties and to immediately notify battleface if any lost or stolen property mentioned in this claim form is subsequently recovered.*first tick box* Please confirm that you give your authority for battleface claims and their appointed representatives to approach any Third party who holds information relating to the incident given rise to this claim. Such authority will permit the Third part(ies) to release relevant information to battleface to assist in the investigation and resolution of this claim*IMPORTANT Please note that if you do not authorise your agent / third party to deal with the claim, we will not be able to discuss any details of the claim with them due to Data Protection Act regulations. For full details of our Privacy Policy click here Name* First Last Declaration Date* MM slash DD slash YYYY
