Customer Services
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
/
/
National Insurance number of claimant
The claimant(s) relationship to the person named on the schedule
Did you take a Form E111 with you?
No
Yes
If so, did you present it?
No
Yes
Were Cega (the 24 hour Emergency Service shown in the Certificate) contacted?
No
Yes
Date/time & place of accident or onset of illness.
If an accident please give full details
If an illness, please provide details including any previous history of such
Do you have any other Medical Insurance (e.g. BUPA, PPP etc)?
No
Yes
If yes, please provide the name of the Insurance Company and the Policy Number
Did you incur any additional expenses, e.g. change to your travel itinerary, if so please provide details
Were you hospitalised for any period of time, if so what were the times and dates of admission and discharge
Please itemise the expenses for which you are claiming showing by each: The currency, the amount and to whom payment should be made
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