Claim Form - Travel - Non Medical

TRAVEL CLAIM FORM
(OTHER THAN MEDICAL EXPENSES)

FOR OFFICE USE ONLY
Issuing of ce :__________________________ Date of Issue : _____________________ Claim Number : _____________________________
THE ISSUE OF THIS FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY

Please ensure that all questions are answered in Capital Letters
Policy Number
INSURANCE DETAILS
MANDATORY
Name of the Insured

Address for
Correspondence
City State
Pincode Telephone (Land Line No.) -
Mobile E-mail
LOSS OF BAGGAGE AND / OR PASSPORT

Date of the Loss D D M M Y Y Y Y Time of Loss H H M M AM PM
Place of Loss (Country/City/Area)
Circumstances of loss
Was the loss reported to the Police ? YES NO

If 'Yes' please give the address of the Police Station.
If 'No' please give reasons why
Police Crime reference No.
Was the loss reported to the Transport provider/Appropriate authority/ YES NO

Hotel or Consulate authority ?
If 'Yes', please give full name and address to whom the loss was reported
If 'No', please give reasons why
Has the claim been lodged on the appropriate authority ? YES NO

If 'Yes', please provide full details
If 'No', please give reasons why
LOSS OF BAGGAGE
Date of Purchase Full description of item Sum claimed for Present Value
Total
Please enclose
Copy of written complaint made to the Police Reply received from the relevant authorities
Copy of written complaint made to Transport Provider. Property Irregularity Report from airline authorities.
Copy of written complaint made to Hotel Authorities / Appropriate Authorities Letter of Subrogation
Non-traceable certi cate from the Police Copies of bills, if any
LOSS OF PASSPORT
Passport Number Expiry date of Passport Date of Expense Description of Expense Expenses claimed
Please enclose Total
Copy of written report made to police or immigration Original bills and receipts for expenses claimed.
authority or consular authority.
Reply received from the relevant authorities. Copy of fresh / duplicate passport.
DELAY OF CHECKED IN BAGGAGE
Name of the Airline
Baggage check number issued by the airline
Date and time of your arrival at your destination D D M M Y Y Y Y H H M M AM PM
Date and time of receipt of your baggage at your destination D D M M Y Y Y Y H H M M AM PM

Duration of delay
Date of Expense Description of Expense Expenses Claimed
Total
Please enclose
Copy of complaint made to the airline.
Certi cate from airline con rming the period of delay.
Original bills and receipts for expenses claimed.
DELAYED FLIGHT
Date and time of Scheduled departure D D M M Y Y Y Y H H M M AM PM
Date and time of actual departure D D M M Y Y Y Y H H M M AM PM
Duration of delay
Date of Expense Description of Expense Expenses Claimed
Total
Please enclose
Certi cate from airline con rming the period of delay of ight.
Original bills and receipts for items claimed.
DETAILS OF OTHER INSURANCE COVERING THIS LOSS.

Company Name & Address Policy Number Sum Insured Period of Insurance
Has a claim been reported to any other Insurer in respect of this incident ? YES NO
If 'Yes' please provide full details
DECLARATION
I hereby declare that the foregoing statements made are true and correct to the best of my knowledge and I have not attempted to conceal anything of material
importance. I agree that if I have made, or will make any false or fraudulent statement whatsoever, the policy shall be void and my right to compensation forfeited.
Place: ........................................................................... Date: D D M M Y Y Y Y
Signature or thumb impression of the Insured
Please check that all questions have been completed in full and the form signed, dated and the required documents / bills attached.
Royal Sundaram General Insurance Co. Limited

(Formerly known as Royal Sundaram Alliance Insurance Company Limited)
Vishranthi Melaram Towers, No. 2 / 319, Rajiv Gandhi Salai (OMR), Karapakkam, Chennai - 600097. Registered Office: 21, Patullos Road, Chennai - 600 002.
Royal Sundaram IRDAI Registration No.102 | CIN: U67200TN2000PLC045611
1860 425 0000 [email protected] www.royalsundaram.in

PR15191/OCT15

Claim Form - Travel - Non Medical

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Claim Form - Travel - Non Medical

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TRAVEL CLAIM FORM

(OTHER THAN MEDICAL EXPENSES)

Issuing of ce :__________________________ Date of Issue : _____________________ Claim Number : _____________________________

THE ISSUE OF THIS FORM IS NOT TO BE TAKEN AS AN ADMISSION OF LIABILITY

Name of the Insured

Pincode Telephone (Land Line No.) -

LOSS OF BAGGAGE AND / OR PASSPORT

Place of Loss (Country/City/Area)

Was the loss reported to the Police ? YES NO

Police Crime reference No.

Was the loss reported to the Transport provider/Appropriate authority/ YES NO

Has the claim been lodged on the appropriate authority ? YES NO

Please enclose Total

Baggage check number issued by the airline

Date and time of your arrival at your destination D D M M Y Y Y Y H H M M AM PM

Date and time of receipt of your baggage at your destination D D M M Y Y Y Y H H M M AM PM

Date of Expense Description of Expense Expenses Claimed

Date and time of actual departure D D M M Y Y Y Y H H M M AM PM

Date of Expense Description of Expense Expenses Claimed

DETAILS OF OTHER INSURANCE COVERING THIS LOSS.

If 'Yes' please provide full details

Place: ........................................................................... Date: D D M M Y Y Y Y

Signature or thumb impression of the Insured

Royal Sundaram General Insurance Co. Limited

1860 425 0000 [email protected] www.royalsundaram.in

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Issuing of ce :________________ Date of Issue : _ Claim Number : ___________________