In order that we can process your claim efficiently, please answer the following questions about the claimant:

Title	First Name	Surname
Mr Mrs Miss Ms Dr Rev Other..
Policy Number
Claim Number (if already known)
Date of birth DD/MM/YYYY		/ /
The claimant(s) relationship to the person named on the schedule
If the claim is for Curtailment were Cega (the 24 hour Emergency Service shown in the Certificate) contacted?		No Yes
Reason for the trip being cancelled/curtailed showing the name of the person whose illness/ injury resulted in the Cancellation/ Curtailment of the trip
Details of the amounts (including dates) paid, refunds obtaindand the amount being claimed