MEDICAL EXPENSE REIMBURSMENT

PERSONAL DETAILS

*required

Travel Insurance Policy Number^*

Surname^*

Email Address^*

Mobile Number^*

*required

Country of Destination^*

*required

Incident Date^*

Please advise the circumstances and the exact nature of the injury or illness giving rise to this claim^*

Date of Treatment^*

Country of Treatment^*

Expenses^*

Add More Expenses

Should the policyholder be the main person of contact?^*

Phone^*

if nothing is attached, documents will be requested at a later date

please upload the passport identification page together with the residency page, if applicable and stamp/visa page, if applicable

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Residency proof

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Visa/ Entering-Exist Stamp from visited country

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Copy of Travel Tickets

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Medical Reports

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Invoices for Medical Expenses

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*required

Claimant Name^*

I have read and accepted the personal data collection consent