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

Notes

1. Please send in ALL original documents. Copies should be kept for your own records
2. Please attach to this claim form sales vouchers, invoices, monthly statements and any other supporting documentation that substantiates the claim and demonstrates the amount claimed
3. You must notify us of a claim within 45 days of the event. If you do not, we will not pay

Please answer ALL Questions Below - BLOCK CAPITALS PLEASE

1. Name and address of your Bank

Contact name at bank
Telephone number
Policy number

2. Name and address of your company

Contact name at company
Telephone number

3. Name of cardholder		Date of joining the company
Card number		Amount claimed

Note - If more than one cardholder is involved, please complete a claim form for each and sumit all together

What references were taken when the cardholder was employed?

4. Date of discovery of loss		Date of loss
Circumstances in which the loss was discovered
Summary of fraud (Use a separate sheet if necessary)
What action has been taken to recover the loss?

5. Has the loss been reported to the police?		YES	NO
Crime reference number		Date reported
Has an arrest been made?		YES	NO

6. Please give full details of the system in force at the time for the checking the business card account of the cardholder

7. When was the cardholder's account last checked and found in order?

By whom ?
Had previous irregularities been detected?	YES	NO

If yes, please give details

Does the cardholder admit responsibility for the fraud?

YES

NO

If yes, please provide details of any explanation given

8. What sums are due to the cardholder from the company?

(These will be deducted from any final settlement)

9. Is the loss covered by any other insurance policy?

YES

NO

If yes, please provide details of the insurer and the policy number

10. Is the cardholder a member of a pension or benevolent fund?	YES	NO
If yes, is any refund of contributions provided and what would be the amount?

11. Minimum standards of control

Has the card been placed on a lost / stolen card list with the bank?	YES	NO
Date:
Has the cardholder's employment been terminated ?	YES	NO
Date:
Has the company written to the cardholder instructing him / her to pay all outstanding charges to the bank and informing him / her to stop all card use?	YES	NO
Date:
Has the card been retreived and returned to the bank?	YES	NO
Date:
Have any payments for outstanding charges been received?	YES	NO
Date:

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