MAPFRE Middlesea Travel Insurance Claim form

Cancellation and abandonment
Date of cancellation/abandonment: *

Day Month Year
Date
Is the cancellation related to: ? *

Death Injury Illness None of the above
Please give reasons for cancellation/abandonment. *
State the item being claimed and respective amounts *
Was the travel agent/ticketing office notified immediatly of the cancellation *

Yes No
Please specify the amounts recovered, if any (Attach any relevant booking conditions
Please upload any relevant documentation *

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- Hotel Accommodation vouchers/receipts
- Flights invoices and receipts
- Tour/holiday programme
- Medical report/s, Death certificates and/or other supporting documentation
- Refund confirmation for unused flights etc
In the event of cancellation you are kindly asked to notify the travel agent/ticket issuing office immediately and apply for the refund of taxes and other dues.

Personal accident
Date and Time of Accident *

Day Month Year
Hour Minutes
Accident Day
Calculated field
There is something wrong with the dates selected. Please check
Place of accident *
Give full description of the circumstances and details of the injury: *
Has claimant been totally disabled as a result of this accident?

Yes No
When did total disablement start?

Day Month Year
Date
Is claimant still totally disabled?

Yes No
When does claimant expect to resume part, if not all, normal business?

Day Month Year
Date

Medical emergency and associated expenses
Date of occurrence *

Day Month Year
Date
Occurrence Day
Calculated field
There is something wrong with the dates selected. Please check
Give details of injury or illness necessitating medical attention: *
Please specify the amounts recovered, if any (Attach any relevant booking conditions
Please specify details of any Private Health Insurance which also covers you for the above expenses *
Please attach the relevant receipts *

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- Medical Report/s and medical invoices and/or receipts
- Hospital reports and hospital invoices and/or receipts (In-patients hospital treatment or surgery is to be notified and authorized by MAPFRE Middlesea plc)
- Refund Confirmation for unused flights etc
- Receipts for additional accommodation and traveling

Hospital benefit
Reason for admittance to hospital: *
Date and time admitted to hospital *

Day Month Year
Date Hour Minutes
Admitted Day
Calculated field
There is something wrong with the dates selected. Please check
Date and time discharged from hospital *

Day Month Year
Date Hour Minutes
Discharge Day
Calculated field
There is something wrong with the dates selected. Please check
Attach hospital report *

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A picture taken from your phone is acceptable Cancel of

Medical information
Name of doctor giving initial treatment in respect of this illness or injury: *

Prefix First Name Last Name
Address *

Street Address

Street Address Line 2

Town Country
Has the person concerned ever suffered from this type of illness or injury before? *

Yes No
General Details *
Please utilise this area to record any sickness /illness that may have been denoted above
Name of usual doctor

Prefix First Name Last Name
Email
example@example.com
Contact Number
DECLARATION

I authorise MAPFRE Middlesea p.l.c. to share information with others (including insurers and Insurance Associations) in order to prevent fraudulent claims. I declare that all the answers given and the statements made are true and correct. Furthermore I declare that I have not withheld any information relevant to the claim. I give explicit and unequivocal consent to MAPFRE Middlesea p.l.c. to seek any information from any doctor, surgeon, hospital, clinic, laboratory or persons that have records or knowledge of my health in order for the validity of the claims to be established. I hereby authorise any doctor, surgeon, hospital, clinic, laboratory or persons that have records to provide full medical information concerning myself and my dependants. I give consent to MAPFRE Middlesea p.l.c. to process my personal data supplied by myself or any person, body or entity in order to process, handle and settle the claim
Date *

Day Month Year
Date
Is the device that you are using to complete this claim form touch capable (ex: Mobile phone/tablet) *

Yes No
Patient’s signature (If the patient is under 18 years of age, then the legal guardian must sign) *
Please upload an image of your signature or alternatively your ID. Card/Passport *

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Cancel of

Delayed/missed departure
Reasons for delayed or missed departure: *
Original
Flight Number *
Date *

Day Month Year
Date
Reschedule
Flight Number *
Date *

Day Month Year
Date
State the item being claimed and respective amounts *
Please upload any relevant documentation *

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Delayed Departure
- Boarding Pass for Actual Departure
- Reason for delay sustained duly supported by documentation (Airline declaration/Newspaper cutting etc)
Missed Departure
- Airline's declaration to confirm refunds for the unused flights
- Receipts for extra charges incurred
- New flight ticket
- Supporting evidence & prove why departure was missed

Lost, damaged or delayed luggage
What happened to your luggage? *

Lost Stolen (Theft) Damaged Delayed
Date and time of loss, theft or damage *

Day Month Year
Date
Occurrence day
Calculated field
Date luggage delivered *

Day Month Year
Date
Place of delivery *
Was the airline notified of your loss, damage or delay? *

Yes No
Were the police notified of loss and/or theft? *

Yes No
Date police notified

Day Month Year
Date
Police Station Notified
State the precise circumstances in which loss, theft, damage or delay occurred: *
Provide the type, make and value of the luggage that you are claiming for *
Please upload any relevant documentation

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Damaged Suitcase
- Original Damage Report by Airline, Original Baggage Tags/Original Baggage Check Receipts
- If a report is not filed at the airport, insured is to lodge a report in writing with the Airline within seven days from date of flight
Non-Delivery of Suitcase
- Original Property Irregular Report
- Airline Baggage Check Receipt
Stolen Items:
- Police report or Airline report or Hotel report within 24hrs of loss
- Receipts/Valuations/manuals/accessories of stolen items (if available)
- Quote/s replacement of same or similar item/s
- Claimants may be requested to make a sworn statement (affidavit)
Delayed Luggage
- Original Property Irregularity Report
  Receipts of suitcase when collected/returned or similar documentation
- Original baggage - check Receipt
- Original receipts for emergency expenses incurred
In case item cannot be repaired:
- Damage item and accessories

Vehicle policy excess
Description of damage sustained to leased/rented vehicle *
Car hire company name *
Make *
Model *
License Plate No. *
Rental agreement dates *
Please upload any relevant documentation *

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Cancel of

Legal liability to others
Description of event *
Were the police notified of the event? *

Yes No
Date police notified

Day Month Year
Date
Police Station Notified
Was someone's other then you and/or your travelling companions property damaged? *

Yes No
Description of the property damaged
Was someone's other then you and/or your travelling companions injured in the event? *

Yes No
Details of injuries sustained
Please upload any relevant documentation

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Cancel of

Signatures
I/We hereby declare that the above information and statements are, to the best of my/our knowledge and belief, correct and complete.
Date

Day Month Year
Date
Is the device that you are using to complete this claim form touch capable (ex: Mobile phone/tablet) *

Yes No
Signature of policy holder *
Please upload an image of your signature or alternatively your ID. Card/Passport *

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Proof of policy holder Cancel of
Date

Day Month Year
Date
Signature of policy claimant *
Please upload an image of your signature or alternatively your ID. Card/Passport *

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Proof of Policy Claimant Cancel of
DATA PROTECTION
MAPFRE Middlesea p.l.c. is legally bound to follow the provisions of the Data Protection Act, 2001. MAPFRE Middlesea p.l.c. is registered with the Office of the Commissioner for Data Protection to process data in accordance with this Act. The Data Protection Policy of MAPFRE Middlesea p.l.c. is compliant with this Act, a copy of which is available on request.

MAPFRE Middlesea p.l.c. (C-5553) is authorised by the Malta Financial Services Authority to carry on both Long Term and General Business
under the Insurance Business Act, 1998.
Please provide your IBAN number to facilitate any claim payments *
Ex: MT-14-AAAA-12345-716542314526178652
Should be Empty:

Cancellation and abandonment

Personal accident

Medical emergency and associated expenses

Hospital benefit

Medical information

Delayed/missed departure

Lost, damaged or delayed luggage

Lost, theft or damaged personal belongings, money and passport

Vehicle policy excess

Legal liability to others

Signatures