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TRIP CURTAILMENT
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PERSONAL DETAILS
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Trip Details
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Claim Details
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Supporting documents
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Signature
PERSONAL DETAILS
*required
Travel Insurance Policy Number
*
Policy number field required
Surname
*
Surname Field Required
Forename
*
Title
*
Mr.
Mrs.
Miss.
Date of Birth of the Claimant
*
Postal Address
*
Email Address
*
Email Address Field Required
Invalid email address.
Mobile Number
*
971
27
1
7
20
30
31
32
33
34
36
39
40
41
43
44
45
46
47
48
49
51
52
53
54
55
56
57
58
60
61
62
63
64
65
66
70
81
82
84
86
90
91
92
93
94
95
98
212
213
216
218
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
242
243
244
245
246
248
249
250
251
252
253
254
255
256
257
258
260
261
262
263
264
265
266
267
268
269
290
291
297
298
299
350
351
352
353
354
355
356
357
358
359
370
371
372
373
374
375
376
377
378
380
381
382
385
386
387
389
420
421
423
500
501
502
503
504
505
506
507
508
509
590
591
592
593
594
595
596
597
598
599
670
672
673
674
675
676
677
678
679
680
681
682
683
684
685
686
687
688
689
690
691
692
850
852
853
855
856
880
886
960
961
962
963
964
965
966
967
968
970
972
973
974
975
976
977
992
994
995
996
998
1242
1246
1264
1268
1284
1340
1345
1441
1473
1649
1664
1670
1671
1684
1758
1767
1784
1787
1809
1868
1869
1876
7370
Mobile Number Field Required
Invalid phone number. A valid number should be between 6 and 15 digits.
Trip Details
*required
Country of Destination
*
Select Country
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (Timor-Leste)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia, Federated States of
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar (Burma)
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City (Holy See)
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Country Of Destination Field Required
Claim Details
*required
Incident Date
*
Incident Date Field Required
Invalid date format
Person of contact
Should the policyholder be the main person of contact?
*
Yes
No
Name
Name Field Required
Relationship
Relationship Field Required
Phone
*
971
27
1
1
7
20
30
31
32
33
34
36
39
40
41
43
44
45
46
47
48
49
51
52
53
54
55
56
57
58
60
61
62
63
64
65
66
70
81
82
84
86
90
91
92
93
94
95
98
212
213
216
218
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
242
243
244
245
246
248
249
250
251
252
253
254
255
256
257
258
260
261
262
263
264
265
266
267
268
269
290
291
297
298
299
350
351
352
353
354
355
356
357
358
359
370
371
372
373
374
375
376
377
378
380
381
382
385
386
387
389
420
421
423
500
501
502
503
504
505
506
507
508
509
590
591
592
593
594
595
596
597
598
599
670
672
673
674
675
676
677
678
679
680
681
682
683
684
685
686
687
688
689
690
691
692
850
852
853
855
856
880
886
960
961
962
963
964
965
966
967
968
970
972
973
974
975
976
977
992
994
995
996
998
1242
1246
1264
1268
1284
1340
1345
1441
1473
1649
1664
1670
1671
1684
1758
1767
1784
1787
1809
1868
1869
1876
7370
387
389
420
421
423
500
501
502
503
504
505
506
507
508
509
590
591
592
593
594
595
596
597
598
599
670
672
673
674
675
676
677
678
679
680
681
682
683
684
685
686
687
688
689
690
691
692
850
852
853
855
856
880
886
960
961
962
963
964
965
966
967
968
970
971
972
973
974
975
976
977
992
994
995
996
998
1242
1246
1264
1268
1284
1340
1345
1441
1473
1649
1664
1670
1671
1684
1758
1767
1784
1787
1809
1868
1869
1876
7370
Mobile Number Field Required
Invalid phone number. A valid number should be between 6 and 15 digits.
Email Address
Email Address Field Required
Invalid email address.
Country of Residence
*
Select Country
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (Timor-Leste)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia, Federated States of
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar (Burma)
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City (Holy See)
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Country of Residence Required
Please explain in a few words why you needed to curtail your trip
*
Reasons Field Required
Trip Start Date
*
Date Field Required
Invalid date format
Time
*
Place
*
Date of Return
*
Date Field Required
Invalid date format
Date you should have returned.
*
Date Field Required
Invalid date format
Number of Days Missed.
*
Days Missed Field Required
Please advise the circumstances
*
Is your curtailment due to medical reasons?
*
Yes
No
Has treatment been sought for this or any other related illness in the past? If yes, provide details including the contact details of your treating doctor
*
Treatment Field Required
Contact Details
*
Expenses
*
-- Select --
AED
AFN
ALL
AMD
AOA
ARS
AUD
AWG
AZN
BAM
BBD
BDT
BGN
BHD
BIF
BMD
BND
BOB
BRL
BSD
BTN
BWP
BYR
BZD
CAD
CDF
CHF
CLP
CNY
COP
CRC
CUP
CVE
CZK
DJF
DKK
DOP
DZD
EGP
ERN
ETB
EUR
FJD
FKP
GBP
GEL
GHS
GMD
GNF
GTQ
GYD
HKD
HNL
HRK
HTG
HUF
IDR
ILS
IMP
INR
IQD
IRR
ISK
JEP
JMD
JOD
JPY
KES
KGS
KHR
KMF
KPW
KRW
KWD
KYD
KZT
LAK
LBP
LKR
LRD
LSL
LTL
LVL
LYD
MAD
MDL
MGA
MKD
MMK
MNT
MOP
MRO
MUR
MVR
MWK
MXN
MYR
MZN
NAD
NGN
NIO
NOK
NPR
NZD
OMR
PAB
PEN
PGK
PHP
PKR
PLN
PRB
PYG
QAR
RON
RSD
RUB
RWF
SAR
SBD
SCR
SDG
SEK
SGD
SHP
SLL
SOS
SRD
SSP
STD
SVC
SYP
SZL
THB
TJS
TMT
TND
TOP
TRY
TTD
TWD
TZS
UAH
UGX
USD
UYU
UZS
VEF
VND
VUV
WST
XAF
XCD
XOF
XPF
YER
ZAR
ZMW
ZWL
Please select a currency
Paid
Not Paid
Add More Expenses
Do you have any private medical insurance?
*
Yes
No
Medical Insurance Field Required
Please provide policy number
*
Policy Number Field Required
Please provide name and address of your private medical insurance
*
Provider Name and Address Field Required
If you did not contact us for medical assistance prior to curtailing, please explain your reasons.
Reason Field Required
Estimated financial loss
Expenses
*
-- Select --
AED
AFN
ALL
AMD
AOA
ARS
AUD
AWG
AZN
BAM
BBD
BDT
BGN
BHD
BIF
BMD
BND
BOB
BRL
BSD
BTN
BWP
BYR
BZD
CAD
CDF
CHF
CLP
CNY
COP
CRC
CUP
CVE
CZK
DJF
DKK
DOP
DZD
EGP
ERN
ETB
EUR
FJD
FKP
GBP
GEL
GHS
GMD
GNF
GTQ
GYD
HKD
HNL
HRK
HTG
HUF
IDR
ILS
IMP
INR
IQD
IRR
ISK
JEP
JMD
JOD
JPY
KES
KGS
KHR
KMF
KPW
KRW
KWD
KYD
KZT
LAK
LBP
LKR
LRD
LSL
LTL
LVL
LYD
MAD
MDL
MGA
MKD
MMK
MNT
MOP
MRO
MUR
MVR
MWK
MXN
MYR
MZN
NAD
NGN
NIO
NOK
NPR
NZD
OMR
PAB
PEN
PGK
PHP
PKR
PLN
PRB
PYG
QAR
RON
RSD
RUB
RWF
SAR
SBD
SCR
SDG
SEK
SGD
SHP
SLL
SOS
SRD
SSP
STD
SVC
SYP
SZL
THB
TJS
TMT
TND
TOP
TRY
TTD
TWD
TZS
UAH
UGX
USD
UYU
UZS
VEF
VND
VUV
WST
XAF
XCD
XOF
XPF
YER
ZAR
ZMW
ZWL
Please select a currency
Add More Expenses
Supporting documents (Max 10MB)
if nothing is attached, documents will be requested at a later date
The files you have uploaded have exceeded the maximum amount (10 MB).
Copy of Passport (identification page)
Copy of Passport (identification page)
Upload a file
Files Only (.jpg, .pdf, .png, .jpeg )
Residency proof
Upload a file
Files Only (.jpg, .pdf, .png, .jpeg )
Visa/ Entering-Exist Stamp from visited country
Upload a file
Files Only (.jpg, .pdf, .png, .jpeg )
Copy of Travel Tickets
Copy of Travel Tickets
Upload a file
Files Only (.jpg, .pdf, .png, .jpeg )
Proof of Early Return
Proof of Early Return
Upload a file
Files Only (.jpg, .pdf, .png, .jpeg )
Proof of expenses lost
Proof of expenses lost
Upload a file
Files Only (.jpg, .pdf, .png, .jpeg )
Medical Report
Medical Report
Upload a file
Files Only (.jpg, .pdf, .png, .jpeg )
Receipts of Expenses
Receipts of expenses
Upload a file
Files Only (.jpg, .pdf, .png, .jpeg )
Incident Report From Third Party (police report, home insurance report, certificate of death…)
Incident report from third party
Upload a file
Files Only (.jpg, .pdf, .png, .jpeg )
Signature
*required
Claimant Name
*
Name Field Required
I have read and accepted the
personal data collection consent
You should approve Privacy and Policy terms