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

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. All original receipts for expenses
4. If treated as out patient, please use 1 line per visit in Medical Expense Schedule
5. If you have suffered from the injury or illness before you must ask your doctor to complete 'Section 3- Medical Certificate'

Please answer ALL Questions Below - BLOCK CAPITALS PLEASE

1. Date of onset of illness/injury

2. Were you admitted to hospital ?

YES NO

3. Description of illness/injury

4. Hospital/Clinic details

Name
Address
Telephone
Treating Doctors Name
Date Admitted
Date Discharged
Number of Days in hospital
Form E111 used?

5. Have you suffered from the condition in the past?

NO YES (Ask GP to complete Section 3)

6. Did you call 24hr emergency service?

Date of first call
Time of first call
Person spoken to and reference no

7. Medical Expenses (continue on seperate sheet if necessary)

Date	Description of item	Bill From	Currency Amt	UK £	Paid - Yes/No

8. Details Of BUPA, PPP, Medical Insurance or Personal Accident Cover you may have

Policy no.
Renewal Date
Insurance Company Name
Address of Insurance Co.

This Section is to be completed by usual GP

Notes:

1. This form is required to support all cancellation, curtailment, personal accident and medical expense claims
2. Any charges made by the Doctor completing this form are NOT recoverable from the insurance
3. To help your doctor please fill in name and surgery details irrespective of whether they or the consultant are to give medical information
4. DOCTORS - Please use block capitals when completing this form

1. Patient Details

Patient Name
Patient Age

2. Doctors Details

Are you the usual GP/Locum?
If yes, for how long?
GP Name
GP Address
Tel. No.
Fax No.
If no, relationship to patient
Name
Qualification
Address
Tel. No.
Fax. No.

3. General Questions

Was patient fit to travel when booking
Would destination or climate affect the patient
Was patient contravening medical advice
Was condition sole reason for cancellation
CANCELLATION - was it NECESSARY
CURTAILMENT - was it NECESSARY

4. Give full description of injury or illness

i. Original consultation date
ii. How long has patient had condition prior to 4(i)
iii. Consultation date - this episode
iv. Date patient advised to cancel
v. When will patient be fit to travel

5. Give details of medical history related to the condition giving rise to the claim

6. At date of booking your Business Trip were you aware of any relevant medical condition

7. PREGNANCY Questions

Date confirmed
Est. Date of Confinement

What condition associated with the pregnancy has led to your advice not to travel?

8. DOCTOR'S DECLARATION

I declare that I have examined the patient named above and/or have referred to their medical records and confirm that the information given above is a true and accurate statement, and further that no material information has been withheld.

Signature
Print Name
Date Signed
Surgery Stamp:

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