Claim Form

Section A (Information to be completed by cardholder):

Observation: To avoid delays in the claim process, pleaseanswer each question in detail.

Certificate number: / Click here to enter text. / Passport number: / Click here to enter text. /
Departure date: / Click here to enter a date. / Return date: / Click here to enter a date. /
(MM/DD/AA) / (MM/DD/AA)
Cardholder: / Click here to enter text. / Date of birth: / Click here to enter a date. /
(MM/DD/AA)
Name ofEligible Dependent: / Click here to enter text. / Date of birth: / Click here to enter a date. /
Gender: / Choose an item. / (MM/DD/AA)
E-mail: / Click here to enter text. /
Address of cardholder or claiming person: / Click here to enter text. /
Type of claim: / Choose an item. / Date of occurrence: / Click here to enter a date. /
Other (Explain): / Click here to enter text. / (MM/DD/AA)
Brieflyexplainwhere, what happened, and under what conditions:
Click here to enter text. /

If filing a Medical Claim:

Have you previously had similar symptoms to those you are experiencing to file this claim? / Choose an item. /
Have you previously received treatment for this problem? / Choose an item. /
If affirmative, where and for how long? / Click here to enter text. /
Physician name: / Click here to enter text. /
Physician address: / Click here to enter text. /
Physician contact information: / Click here to enter text. /

Section B - Authorization

I hereby authorize any physician, hospital, clinic or other medical or medically related facility that is licensed as such,insurance company, Medical Information Bureau or other organization, institution or person who has any information about my health, or my spouse or dependent child(ren) if he/she is listed under the plan as Eligible Dependent(s), to give such information to Redbridge Travel and its representatives. A photocopy of authorization shall be as valid as the original.

Cardholder signature:
Eligible Dependent signature (if over 18 yearsold):
Date: / Click here to enter a date. /
(MM/DD/AA)

Steps to initiate a claim:

  1. Notify the service company within 48 hours of the event.
  2. Send Claim form properlycompleted and signed.
  3. Submit required documentation.

Documents required for filing medical claims:

  • Original itemized bill showing diagnosis and description of each procedure, bill and service date.
  • Physician report showing the treatment plan.

Documents required for filing non-medical claims:

  • Send the original documentation from all official sources to support and justify the event.
  • Documentation on claimed condition as:

-Police report.

-Medical certificate / death certificate.

-Certificate issued by the airline or cruise line.

For more details, please refer to the Travel AssistanceServicePlan.

Address to send supporting documentation: PO Box 144490, Coral Gables, FL 33114, USA.

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