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
2. Original Booking Invoice for your Business Trip
3. Send us a fully detailed account of incident damage injuries and names and addresses of any witnesses
4. Send us ALL relevant documentation from any third party - THIS MUST BE UNANSWERED

Special Notes

1. Please use additional sheets of paper to explain your claim
2. Do not under ANY circumstances talk or write to any person regarding the incident as this WILL invalidate claim

Give Details of Claim Below

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