Claim Form

General Information
Contact Information
Name of insured: _________________________________ Social Security Number ______--_____--____________
Date of birth: ____________________________________ Home telephone: (______) ________ -- _____________
Place of birth: ____________________________________ Work telephone: (______) ________ -- _____________
E-mail address: __________________@______________
Home Address Mailing Address, if different from Home Address
Street: _________________________________________ Street: _________________________________________
City: ___________ State: _____ Zip Code: ________ City: _____________ State: ____ Zip Code: _______

Preferred method of contact: Mail E-mail Home Phone Work Phone

Plan Information Trip Information

Confirmation/Policy ID #: ___________________________ Departure date: __________________________________
or Product ID #: __________________________________ Return date: _____________________________________
or Group #: _____________________________________ Original destination: _______________________________
or Company ID #: ________________________________ Travel agency name: ______________________________
or Membership #: ________________________________ Date of initial trip deposit/payment: ____ / ____ / _______
Agent’s name: ___________________________________
Agent’s phone number: (______) ________ -- __________
Agent’s e-mail address: ________________@__________

Traveling Companions (please indicate name and relationship to you)

1. _____________________________________________ 3. _____________________________________________
2. _____________________________________________ 4. _____________________________________________

Claim Information
Reason for filing this claim (short description) ______________ Date incident occurred: ____ / ____ / __________
Do you have other insurance that may cover this
_____________________________________________________
event?
_____________________________________________________ Yes No
If Yes, then please provide the name of the
_____________________________________________________
insurance company __________________________

E-mail to: [email protected]

Mail to: ACCESS AMERICA, P.O. BOX 72031, RICHMOND, VA 23255-2031
Call: 800-334-7525 Fax to: 804-673-1469
We are available 24 hours a day.

Insurance underwritten by BCS Insurance Company or Jefferson Insurance Company

Please refer to your policy or letter of confirmation to determine your underwriter
Plan administered by World Access Service Corp., a company of Mondial Assistance
 Trip Cancellation / Trip Interruption / Travel Delay / Missed Connection

Details of Loss
Please describe in detail all circumstances that caused your cancellation, interruption, or delay (attach additional pages if
needed):
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Did you contact your travel agent or travel supplier when you cancelled or interrupted this trip?
Yes Date______________ No

Was the reason for the trip cancellation, interruption, or delay of a medical or non-medical nature?
Medical Non-Medical

ƒ Please complete this entire form.

ƒ Attach the enclosed Physician Statement Form

completed by an appropriate physician. Please skip to the Claimed Expenses section below.
ƒ If your cancellation, interruption, or delay was due to
someone’s death, please attach a copy of the death
certificate.

Details of Medical Condition

Name of patient: _________________________________ Relationship to named insured: ______________________
Nature of medical condition: ________________________ Date condition first began: __________________________
_______________________________________________ Date of first treatment: _____________________________
Were you treated for this condition prior to the purchase of this insurance? Yes No
If this is an accident resulting in injury, was an accident report completed? Yes No
(Please enclose a copy)
Please list doctors consulted for this condition.
Name Address Phone Last seen on
1. _________________ ___________________________________________ (___) ___ - ______ ___/___/____
2. _________________ ___________________________________________ (___) ___ - ______ ___/___/____
3. _________________ ___________________________________________ (___) ___ - ______ ___/___/____

E-mail to: [email protected]

Mail to: ACCESS AMERICA, P.O. BOX 72031, RICHMOND, VA 23255-2031
Call: 800-334-7525 Fax to: 804-673-1469
We are available 24 hours a day

Insurance underwritten by BCS Insurance Company or Jefferson Insurance Company

Please refer to your policy or letter of confirmation to determine your underwriter
Plan Administered by World Access Service Corp., a company of Mondial Assistance
Claimed Expenses
Category Amount Required Supporting Documentation*
Airfare $_______________ E-ticket receipt or original paper airline tickets
Lodging $_______________ Documents confirming your reservation/payment/partial payment
Tour(s) $_______________ Copy of the invoice
Other (list below)
________________ $_______________
Please provide sufficient supporting documentation, such as credit card
________________ $_______________
statements, copies of cancelled checks, receipts, etc.
________________ $_______________
Total Expenses $_______________
Less refunds $_______________ Examples: account credits, cash refunds, trip or meal vouchers, etc.
Total Claimed $_______________
* We reserve the right to request additional information/documentation as needed to process the claim.

PLEASE READ AND SIGN THIS FORM.

FAILURE TO SIGN AND DATE MAY DELAY THE REVIEW OF YOUR CLAIM.

FRAUD WARNING: Any person who knowingly and with intent to injure, defraud or deceive any insurance company or
other person, who files a statement of claim containing any false information, or conceals for the purpose of misleading,
information concerning any fact material thereto, commits a fraudulent insurance act, which may be a crime and may be
subject to criminal prosecution, civil penalties and forfeiture of insurance benefits.

ALASKA FRAUD WARNING: A person who knowingly and with intent to injure, defraud, or deceive an insurance
company files a claim containing false, incomplete or misleading information is guilty of a felony.

CALIFORNIA FRAUD WARNING: Any person who knowingly presents false or fraudulent claim for the payment of a loss
is guilty of a crime and may be subject to fines and confinement in state prison.

PENNSYLVANIA FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or
other person files an application for insurance or statement of claim containing any materially false information or
conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance
act, which is a crime and subjects such person to criminal and civil penalties.

AUTHORIZATION

I authorize any insurance company, travel organization, or any other person or entity to release information regarding this
claim. I understand that this information will be used by World Access Service Corp., claim administrator, or its authorized
representatives for the purpose of evaluating and determining coverage for this claim.

By signing this claim form, I certify that all information given above is true and complete to the best of my knowledge.

Signature: ________________________________________ Date Signed: ____/____/_____

Print Name: _______________________________________

The status of your claim can be easily viewed at www.eclaimsline.com/travel by clicking on the “Check Claim Status” link.

E-mail to: [email protected]

Mail to: ACCESS AMERICA, P.O. BOX 72031, RICHMOND, VA 23255-2031
Call: 800-334-7525 Fax to: 804-673-1469
We are available 24 hours a day

Insurance underwritten by BCS Insurance Company or Jefferson Insurance Company

Please refer to your policy or letter of confirmation to determine your underwriter
Plan Administered by World Access Service Corp., a company of Mondial Assistance
 Physician Statement Form

To be completed by Primary Insured

Primary Insured’s Name: ___________________________
Policy Number: ___________________________________
Insurance Purchase Date: ____ / _____ / _________

To be completed by Examining Physician

Patient Information
Patient’s Name: ___________________________________
Date of Birth: _____ / ________ / _____________
Street Address: ___________________________________ City: ______________ State: ____ Zip Code: _______

Physician Information
Examining Physician’s Name: ________________________ Specialty: _______________________________________
Street Address: ___________________________________ City: ______________ State: ____ Zip Code: _______
Phone: (______) ______ -- ____________ Fax: (______) ______ -- ____________

Are you the patient’s primary care physician?

No
Who is this patient’s primary care physician?
Name: __________________________________________
Yes Phone: (_____) _______ -- ___________
Was the patient referred to you by the primary care
physician?
Yes No

E-mail to: [email protected]

Mail to: ACCESS AMERICA, P.O. BOX 72031, RICHMOND, VA 23255-2031
Call: 800-334-7525 Fax to: 804-673-1469
We are available 24 hours a day.

Insurance underwritten by BCS Insurance Company or Jefferson Insurance Company

Please refer to your policy or letter of confirmation to determine your underwriter
Plan Administered by World Access Service Corp., a company of Mondial Assistance
 Patient’s Diagnosis:
Did you perform an actual examination? Yes No
Date of the exam: ____ / _____ / _________
Please indicate the primary diagnosis for which you examined the patient:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
ICD-9 Code: _______________
Date symptoms first appeared or accident occurred: ____ / _____ / _________
Is this condition a complication of an underlying condition? Yes (specify below) No
__________________________________________________________________________________________________

Please list the dates of the patient’s office visits in the 120 days before the insurance purchase date, noted above. Circle
the dates where you treated the patient for the above stated condition.
____ / _____ / ___________ ____ / _____ / ___________ ____ / _____ / ___________ ____ / _____ / ___________
____ / _____ / ___________ ____ / _____ / ___________ ____ / _____ / ___________ ____ / _____ / ___________

Did you advise the trip be cancelled or interrupted due to the patient’s medical condition?

Yes Date: ___ / ___ / _________ No

Please explain why you made this recommendation. Please explain why you did not make this recommendation.
Provide details on the circumstances and medical diagnosis Provide details on the circumstances and medical diagnosis
of the patient that you consider relevant to the insured’s of the patient that you consider relevant to the insured’s
decision to cancel or interrupt their trip due to injury or decision to cancel or interrupt their trip due to injury or
illness. illness.

________________________________________________ ________________________________________________
________________________________________________ ________________________________________________
________________________________________________ ________________________________________________
________________________________________________ ________________________________________________
________________________________________________ ________________________________________________

If the patient is the insured, on what date did he/she become medically unable to travel? ___ / ___ / ________

By my signature and stamp below, I hereby certify that the above is true and correct

Physician Signature: _________________________________________________ Date ____/____/______

Physician Stamp:

E-mail to: [email protected]

Mail to: ACCESS AMERICA, P.O. BOX 72031, RICHMOND, VA 23225-2031
Call: 800-334-7525 Fax to: 804-673-1469
We are available 24 hours a day.

Insurance underwritten by BCS Insurance Company or Jefferson Insurance Company

Please refer to your policy or letter of confirmation to determine your underwriter
Plan Administered by World Access Service Corp., a company of Mondial Assistance