Notification Form for CISV Insurance Claim

Please use this form to make an insurance claim relating to the Basic Travel or Excess Medical insurance policies obtained via CISV International. If there is more than one Claimant, complete and return a copy of this page for each Claimant.

Please complete all sections of this claim form and note the instructions for additional required documents.

When this form is completed, please sign the declaration below and, return it directly to Intana, Sussex House, Perrymount Road, Haywards Heath, West Sussex RH16 1DN England.

Tel: 0208 865 0791

Email:

POLICY DETAILS

Claim for Travel Policy (YES/NO)
Travel Policy Number
Claim for Excess Medical Policy (YES/NO)
Excess Medical Policy Number

INSURED PERSON’S DETAILS

Insured person’s name
Insured person’s gender (M/F)
Insured person’s date of birth (day/month/year)
Home Address Number & Street
Town / City
Area / State / Province

Country

/

Postcode / Zip code

Country Code / Area Code / Local Number
Tel
Fax
Mobile Number
E mail
Insured person’s home National Association and Chapter
CISV Programme Reference number (e.g. V-2008-11)
Host country of the programme
Start date of travel to the programme (day/month/year)
End date of travel from the programme (day/month/year)

CLAIMANT’S DETAILS

Given Name

Surname
Number & Street
Town / City
Area / State / Province

Country

/

Postcode / Zip code

Country Code / Area Code / Local Number
Tel
Fax
Mobile Number
E mail

FINANCIAL INFORMATION FOR INSURED’S CLAIM REGARDING CLAIMANT / PAYEE (ABOVE):

Currency: / Total amount claimed:
Amount paid to date: / Balance due ( to be paid )

DETAILS OF THE INCIDENT / LOSS

Date of incident / loss (day/month/year)
Place of incident / loss (City and country)
Give a brief description of incident or loss causing claim.
If necessary, enclose a separate page.Please write the name of this form, date and your name at top of each page

OTHER INFORMATION

Was a deductible paid? (Yes / No)
If yes, how much was paid?
If yes, who paid it? (name and CISV position, e.g. leader, home staff)
If yes, to whom or to what organization was it paid? (name)
If claim is for baggage lost or damaged in transit, did you file a claim with the carrier? (Yes / No) Note that a carrier claim is required.
If yes, what is the name of the carrier?
If claim is for theft of property or personal liability, did you notify the police? (Yes / No) Note that notification is required for theft.

Please attach the following data / forms required by One Assist to process your claim:

Medical & Accident Expenses (Basic Travel & Excess policies)
  • Completed CISV Claim form
  • Completed CISV’s Health Form
  • Completed CISV’s Legal Form
  • Certificate of Insurance
  • Treating Physician’s Report
  • Original invoices
/ Personal Liability Claim (Excess policy only)
  • Completed Claim Form
  • Original Invoices
  • Policy Report (if appropriate)

Baggage Claim (Basic Travel policy only)
  • Completed Claim form
  • Carrier’s Report (for baggage lost / damages in transit)
  • Police Report (for stolen property).
  • Originalsinvoice
/ Cancellation Claim (Basic Travel policy only)
  • Completed Claim Form
  • Original invoice for airline tickets and cancellation fee
  • CISV International memo re cancellation of activity NB. No claim for cancellation re illness or
  • family death.

Note:In ALL cases documents must be supplied with the Claim Form at the Claimant’s expense. Failure to do so will delay the processing of your claim and could result in it’s being declined.

I declare that to the best of my knowledge all information contained in this form is true and complete.

False statements will invalidate any claim under this policy.

Signature of Insured

or of parent / guardian ( for minors / (Day / Month / Year)
CISV International Ltd
Official Form / (Valid from 2013) / Page 1 of 2