Medical Claim Form - Abridged

Medical Claim Form - Abridged

Notification of a claim
Policy Details
Policy Number
Date of Purchase/Issued

DayMonthYear
Date
CLAIMANT DETAILS
Policyholder
(If different from claimant)
Relationship to Person Claiming*
If you are person insured enter 'insured'
Name of person claiming*

Surname:First Name
Title*

MrMrsMsMissOther
Date of Birth*

DayMonthYear
Date
Occupation*
Your nationality
Home Address*
Postcode
Home Telephone No

Country CodeArea CodePhone Number
Work Telephone No

Country CodeArea CodePhone Number
Mobile Telephone No*

Country Code
Email*
example@example.com

TRAVEL DETAILS
Country of Destination*
Date Trip Booked*

DayMonthYear
Date
Departure Date*

DayMonthYear
Date
Return Date:*

DayMonthYear
Date
Dates of treatment (If any)
From (Date)

DayMonthYear
Date
To Date:

DayMonthYear
Date
Have you made any other claims for this incident with any other Insurer?*

YesNo
If yes, please provide details:

CLAIMS HISTORY
Have you submitted any other claim form to us in conjunction with this claim?*

YesNo
If Yes, please provide our claim reference number(s):

INCIDENT DETAILS
Incident Date*

DayMonthYear
Date
Describe the circumstances surrounding your claim, including all relevant dates and places:*
Were you injured as the result of an accident?*

YesNo
If yes, describe the circumstances surrounding your accident, including all relevant dates and places:
Details of any third party involved including contact number / third party insurance details:
Are you pursuing legal action in relation to this claim?*

YesNo
If yes, please provide your solicitor’s details:

DETAILS OF TREATMENT
Were you admitted to hospital?*

YesNo
If admitted, please provide date and time of admission and discharge below:
Admission Date

DayMonthYear
Date
Admission Time

Hour Minutes

AM/PM Option
Discharge Date

DayMonthYear
Date
Discharge Time

Hour Minutes

AM/PM Option
Name of Clinic/Hospital
Contact Details
If outpatient treatment, please provide date, time and details of each treatment:
Diagnosis given by treating doctor / hospital:
Did you contact the Collinson 24-hour emergency service at the time of the incident?*

YesNo
Date

DayMonthYear
Date
Time

Hour Minutes

AM/PM Option
Our Reference
If no and your claim is for more than £500, please give a full and detailed explanation of why you failed to contact the emergency service:
(Failure to contact Collinson Emergency Services at the time of the incident may limit the amount of your claim. Please refer to your policy wording for further details).

DETAILS OF EXPENDITURE
List of expenditure / amounts paid by you:
List of outstanding bills still to be paid:
Did you pay your policy excess directly to the hospital at the time of treatment?

YesNo
If yes, please include your receipt and confirm the amount
File Upload

Cancelof
Did you present a Global Health Insurance Card (GHIC) to the doctor / clinic at the time payment was made?*

YesNo
Have you ever been treated for this or any other related condition before?*

YesNo
If yes, please complete the following Medical Declaration below.
For treatment received in Australia: Did you register for Medicare?

YesNo
If no, please comment below as to why:
DECLARATION
I / We confirm that the facts stated in this form to be true and accurate to the best of My / Our knowledge. I / We understand that the information provided in relation to this claim may be shared with other insurers or financial institutions for the purposes of dealing with this claim and eliminating insurance fraud. I / We give authority to the insurers and their representatives to contact My / Our Medical Practitioners for any additional information.

I / We confirm that I / We give authority for you to approach any third party who holds information relating to the incident giving rise to this claim, I / We hereby authorise any such third party to release such information to you to assist in the investigation and resolution of My / Our claim.

I / We hereby grant Collinson (as agent for the underwriter) full rights of subrogation in respect of any payments made on My / Our behalf. I / We further agree to fully co-operate with any such recovery efforts from liable third party or parties.
Please note that if you do not authorise your agent / third party to deal with the claim, we will not be able to discuss any details of the claim with them due to Data Protection Act regulations.
Signature(s)
Date

MonthDayYear
Date
Should be Empty: