Barclaycard Business Landmark House, Hammersmith Bridge London, W6 9DP Tel : 44 (0)20 8762 8014 Fax : 44 (0)20 8762 8072	Claim Ref:
	Date Sent:

Personal Details - Required for all Claims
Mr/Mrs/Miss/Ms		Home Address
Surname
Forenames
Date of Birth
Age		Postcode
Occupation		Home Tel. No.
		Work Tel. No.

Policy/Business Trip Details		Type of Claim	Amount (£)
Card Number		Extended Warranty
Issued by		Cancellation
Travel Agent		Curtailment
Tour Operator		Travel Delay
Date of Booking Business Trip		Medical Expenses
No. in Party		Personal Accident
Depart Date		Baggage/Personal Effects
Return Date		Money
Total Days		Personal Liability
Country		Legal Expense
Resort/Town		Delayed Baggage
Deposit Paid		Purchase Protection
Date		Cardholder Misuse
Balance Paid
Date		Total Amount Claimed
Total Cost

Reason for cancellation:

Death

Accident

Illness

Injury

Non-medical

Documents You Need to Send Us -
SEND ORIGINAL DOCUMENTS BUT KEEP COPIES FOR YOUR RECORDS

1. Original Insurance Certificate (if applicable)
2. Original Booking Invoice for your Business Trip
3. Original Cancellation Invoice for your Business Trip
4. Wherever appropriate ALL UNUSED flight travel tickets
5. If cancellation due to illness - please provide a medical certificate from the treating doctor

OR If cancellation due to death – please provide a medical certificate from the treating doctor and a certified copy of the death certificate

OR If cancellation not caused by death or medical problems send independent WRITTEN evidence supporting reason for cancellation

Please answer ALL Questions Below - BLOCK CAPITALS PLEASE

1. Dates and when travel agent or tour operator advised of Business Trip cancellation

Verbally
In writing

2. If cancellation was due to a person not booked to travel please state name and relationship to the insured person

Name
Relationship

3. Names and Ages of all those cancelling

Name	Age

4. Cancellation charges and payment information

Total Paid to agent
Payment Method
Cancellation Charge
Refund given
Total Amount Claimed

5. Please give details of reason for cancellation

The making of a fraudulent Insurance claim is a criminal offence. You may be prosecuted if you make fraudulent claims. Claim forms cannot be accepted by Fax as original supporting documentation is required for all claims.

1. I/We hereby declare that all information, answers and documents given in connection with this claim are true and correct to the best of my/our knowledge and belief. I/We have not omitted any material information, which would effect the Underwriters judgement of the claim. I confirm that where a claim or claims are made on behalf of others, I have their full authority to act on their behalf, and I confirm that I understand that neither International SOS Ltd nor the underwriters will accept responsibility if any payments are not distributed proportionately to the persons concerned.
2. I/We understand that the information on this form will be passed to or used by International SOS for my insurance, this includes underwriting, processing, handling claims and preventing fraud and could include passing details to agents or other insurers.
3. I/We consent to International SOS contacting my doctor direct to further information from my medical records if required.

I have Read and fully understand the declarations above (ALL persons claiming must sign)

Claimants Name	Age	Claimants Signature	Dated