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 fro your Business Trip
3. All original receipts for expenses
4. Insurance valuations of items of jewellery (MUST be dated earlier than the date of loss)
5. Report from the police, airline, hotel or transport authority to whom you reported your loss
6. Bank or Building Society statements, currency exchange slips etc. in evidence of cash claims

Special Notes

1. Please use additional sheets of paper if your loss or explanation thereof will not fit in the space provided
2. Do not throw any items away unless the Underwriters say you can or they pay claim against the items
3. ANSWER EVERY QUESTION - DO NOT USE DASHES, 'N/A' OR LEAVE BLANK - WRITE 'NONE'

Please answer ALL Questions Below - BLOCK CAPITALS PLEASE

Section A - Information required on claims for baggage, effects, and cash claims

1. Incident Specifics

Date & time of incident
Place of incident

2. Incident Reported To

Police

Holiday Rep.

Shipping Company

Airline

Railway Police

Hotel Owner

Date reported:

3. FULL Details of incident where items were immediately prior to loss or damage

4. Details of the precautions taken to protect your possessions

5. Detail the actions you took to recover your possessions

6. Your household insurance (or any other applicable insurance)

Name & Address of Insurer

Policy No.
Renewal Date

Details of previous claim

ANSWER ALL QUESTIONS IN SECTION A BEFORE COMPLETING SECTION B

Section B - Details of Baggage and Personal Effects Claims

Date Aquired	Description of item	Owner	Purchase Price	Place Purchased	Wear, tear & depreciation	Amount claimed

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