INSTRUCTIONS FOR MAKING A CLAIM
MEDICAL EXPENSES
· Bills and receipt for amounted claims
· Medical report from treating doctor clearly stating the problem (this is not required if you contacted the assistance company and they have been involved in the treatment you have received
PERSONAL EFFECTS INCLUDING MONEY
· Police report if items/money have been stolen
· Receipts, bank statements, photos, packaging to prove ownership of items you are claiming
· Money only –withdrawal of funds that have been stolen
CANCELLATION/CURTAILMENT
· Evidence to support the reason for cancellation
· Evidence of original flights booked
· Evidence that flights cancelled and details of any refund provide
· Evidence of any new flights purchased
DELAY
· Flight tickets for delayed trip
· Letter from the airline confirming the length and reason for the delay
CLAIM FORM Claim Ref: Banner Use Only
Please complete sections 1, 6 and any relevant sections from 2, 3, 4 & 5.
PLEASE RETURN TO:
Banner Financial Services Claims Department, 3, Meridian Office Park, Osborn Way, Hook, Hampshire RG27 9HY
Email: Phone: 0844 846 9911 or +44 (0)1256 748 005 Fax: 0871 277 4200.
Together with ALL receipts, invoices and other documents e.g. medical report, police/carrier report, death certificate, travel agents and airline letters.
PERSONAL DETAILS Section 1
Insurance Certificate Number: Period of Insurance: From: To:
Name of Insured Person(s) / Group: Date of Birth: / /
Claimants name, if different:
Address:
Post Code:
Occupation: Overseas Location:
E-mail: Contact Telephone Number:
Purpose of Journey:
MEDICAL EXPENSES Section 2
Country in which injury or illness occurred:
Date of arrival in country: // Date due to return to home country: //
Date of injury or illness: // Nature of injury or illness:
Have you had vaccinations & preventative treatment for country(s) you are visiting / residing? YES NO
For dental claims please give date of last check up and full details of circumstances of claim: //
Claims may be delayed if information is not provided
Cause of injury or illness:
Name and address of attending doctor or hospital:
Was excess paid direct to Doctor or Clinic? YES NO
Was treatment given in hospital as an in-patient? YES NO
If YES, please give period of hospitalisation: From: To:
Was the Assistance Company contacted, as per policy booklet? YES NO If YES please give date: //
Ref No. if known:
If the cause of this claim is illness, has the Insured Person suffered from the illness before? YES NO
If YES please give details:
Name and address of usual medical attendant in UK:
CANCELLATION CURTAILMENT Section 3
Date journey booked? Date journey cancelled or curtailed? //
Why was the journey cancelled or curtailed?
If the journey was curtailed, was medical attention given abroad? YES NO If YES, please complete the following
Name of the doctor or hospital: Name and age of injured or ill person:
Nature of injury or illness: Cause of injury or illness:
Date injury or illness occurred: //
Has the person suffered from a similar illness before? YES NO Date: //
Has/will any of the ticket money be reimbursed by the Travel Agent? YES NO Please provide documentation from Travel Agent.
PERSONAL EFFECTS Section 4
Date of loss or damage: // Time of loss or damage: am pm
Country where loss or damage occurred:
Circumstances of loss or damage:
Date Police or transport carrier advised: // Police/carrier reference:
Is there any other insurance in force, which may cover this loss? YES NO
If YES, give details including insurer and policy number:
TRAVEL DELAY Section 5
Reason for delay:
Original flight time: Actual flight time:
Did you suffer any financial loss? YES NO
Documentary evidence detailing period and reason for delay MUST accompany this form.
FINANCIAL DETAILS Section 6
The total settlement amount will be subject to an excess (deductible) as shown in the policy document.
Please give details of expenses incurred:
Total amount & currency claimed:
Payment is made directly into a bank account unless you request otherwise. Please be aware that there is a charge of £20 for international payments and this will be deducted from any settlement offered. We are pleased to confirm that there is no charge for payments to UK bank accounts. Please provide us with full bank details in order for us to make the payment:
If UK customer: If International customer:
Name of Account Holder: Name of Account Holder:
Name of Bank or Building Society: Address of Account Holder:
Address of Bank or Building Society Branch: Bank Identifier Code (BIC):
Account Number: International Bank Account Number (IBAN):
Sort Code:
Declaration: I / we hereby declare that these particulars are true and complete to the best of my / our knowledge.
Insured Person’s signature: Date:
In the event of a claim, your personal data may be transferred outside of the EEA. Where this is necessary, your data will be controlled in accordance with the Data Protection Act 1998.
DETAILS OF ALL ITEMS / RECEIPTS FOR YOUR CLAIM
DETAILS OF ITEM / RECEIPT / BILL BEING CLAIMED FOR / Date Purchased(if applicable) / Purchase Price / Currency / Amount Claimed
TOTAL
Any other details:
www.bannergroup.com
Banner Financial Services is a trading name of Harrison Beaumont Insurance Services Ltd who is authorised and regulated by the Financial Conduct Authority. (FCA Registered Number 303968) Registered Office: Globe House, 24 Turret Lane, Ipswich, Suffolk, IP4 1DL.Registered in England & Wales, registration number 4582221 BAN009 (1113)