Blank Travel Insurance Claim Form

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Effective 28 July 2011

This travel insurance is arranged and managed by AGA Assistance Australia Pty Ltd

trading as Allianz Global Assistance (Allianz Global Assistance) ABN 52 097 227 177,

AFSL 245631 and is underwritten by Allianz Australia Insurance Limited (Allianz)

ABN 15 000 122 850, AFSL 234708.

Allianz Global Assistance is authorised by Allianz to enter into and arrange the policy and

deal with and settle any claims under it, as an agent of Allianz, not as your agent.

Email: [email protected]

Phone: 1300 725 154

Facsimile: (07) 3305 7016

Postal Address:

Travel Claims Department

Locked Bag 3038

Toowong DC QLD 4066

Australia

TRAVEL INSURANCE CLAIM FORM

Claim No:

PRIVACY We (Allianz and our agent AGA Assistance Australia Pty Ltd trading as Allianz Global Assistance) collect, use, and disclose your personal information (including sensitive

information) so that we can arrange, manage, and administer the travel insurance services (including any claims) according to our contract with you. We may disclose it to third parties

who assist us carry out these functions and processes. Please see our privacy notice in your Product Disclosure Statement or contact us on 1300 725 154 for a copy. Our corporate privacy

policy is also available at www.allianz-assistance.com.au

INTERNAL DISPUTE RESOLUTION Disputes are not an everyday occurrence, however, Allianz Global Assistance provides an internal dispute resolution process should any dispute arise. Please feel

free to ask for details. If you are not satised with the outcome of this process, we will advise you how to contact the insurance industry’s external independent complaints scheme.

FRAUD Insurance fraud places additional costs on honest policyholders. Fraudulent claims force insurance premiums to rise. We encourage the community to assist in the prevention

of insurance fraud. You can help by reporting insurance fraud. All information will be treated as condential and protected to the full extent under law. Report insurance fraud by

calling 1800 453 937.

STEP 1 – CLAIM FORM COMPLETION REQUIREMENTS

• Please read this claim form carefully and complete ALL steps outlined on this form, including the Declaration on page 7.

• Please use block letters.

• Please retain a copy of ALL documents for your records.

• Documents in a foreign language are required to be translated into English at your own expense.

• The claim form and ALL supporting documentation may be mailed, emailed or faxed to us. Please note: We reserve the right to request the original

receipts, reports or any other documentation be submitted in order to substantiate the claim.

• Please refer to the specied documentation requirements that you will need to provide when lodging your claim. As each claim is unique, further information

may be requested by us.

•  AcopyofyourCerticateofInsurancemustbesuppliedwithyourclaim.

• Ifanypartofyourclaimisofadishonestorfraudulentnature,thenyourclaimwillbedeniedandwillbereferredtotheappropriateauthorities.

STEP 2 – CLAIMANT DETAILS

Policy and Claimant Details

ALL QUESTIONS IN THIS SECTION MUST BE ANSWERED

Name of Policyholder(s)

Name of Claimant (Mr/Mrs/Miss/Ms)

Certicate of Insurance/Policy Number

Address

Postcode

Telephone Home

Business

Mobile

Email Address

Date of Birth

/ /

Occupation

Travel Agent

Date of Booking Travel Arrangements

/ /

Date of Departure

/ /

Date of Return

/ /

Ifyouwishtogiveauthorityforanotherpersontoactonyourbehalfinrespecttothisclaimyoumustcompletethefollowingdetails(otherwisewe

willnotbeabletogiveanyinformationaboutyourclaimtoanyotherperson).

I/We, authorise (Name)

of (Address)

Postcode

Phone

Mobile

to act on our behalf in respect to this claim and to be provided with information relating to the claim.

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