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

EXTENDED WARRANTY

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

1. Original sales receipt
2. Original Visa Voucher, or Barclaycard Business statement as proof of purchase

Special Notes

1. The claim can only be made by the cardholder.
2. You must report any event that may result in a claim and obtain a written report to confirm this within 36 hours of the event.
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. Details of Loss
Please provide details of events that led to this claim

2. Did you report the loss?

YES

NO

Date reported:

3. If YES, please provide details including any written reports or crime reference

4. Details of lost / stolen / damaged items (including make & model)

	Where Purchased	Date Purchased	Purchase Price

5. Is the damage repairable?

YES

NO

Date reported:

6. Other insurance
You MUST complete this section in full. If you do not, it will delay settlement of the claim.

Do you have any other insurance that will cover this loss?

YES

NO

7. Policy number

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