TATA-AIG GENERAL INSURANCE COMPANY LIMITED

AHURA CENTER, 4TH FLOOR,

MAHAKALI CAVES ROAD,
ANDHERI (E), MUMBAI - 400 093
OVERSEAS TRAVEL INSURANCE CLAIM FORM
For Accident / Sickness Medical Expenses Reimbursement Only
IMPORTANT:
Please contact our 24-hour helpline (our Assistance Center) on
For the Americas Policies: 1-866-866-2620 (Toll Free) / Direct Dial - 713-260-5520
Email: tata.aig@aig.com.
For rest of the world policies excluding the Americas:Ph : 0091-11-41898860 / Fax : 0091 - 11 - 41898801
Email: delhi.tata-aig@internationalsos.com
Toll Free in UK : 08009171463, Toll Free in Japan : 00531650255, Toll Free in Germany : 08001800168
Toll Free in Belgium : 080073883 , Toll free in Australia : 1800886629, Toll Free in France : 0800905445
Toll Free in North-China: 10-800-712-2118, Toll Free in South-China : 10-712-120-2118
Failure to call our Assistance Company on 24-hour helpline, in respect of Medical Accident & Sickness Claims shall invalidate your claim,
if any. Please note, the first US$25 of your medical expenses is deductible, and must be borne by you.
1. This is a One Call Claim Form, except for Accidental Death & Dismemberment (ADD). For ADD, we shall provide a separate Claim Form upon notification.
2. Issuance of the form is not an admission of liability or a waiver of terms, conditions & exceptions of the insurance contract.
3. No claim under Accident & Sickness Section will be admitted without Doctor's Report as per format (Attending Doctor's Report - Page 3)
4. Please answer all questions completely. In case of insufficient space, please attach an additional sheet.
5. Please attach all Original bills& receipts pertaining to your claim.
Insurance Card No. / Payana No._____________ Period From ______________TO

DETAILS OF PATIENT/ INSURED PERSON

Name of the Insured :-
Name of the Employee Employee No.
Name of the Claimant Phone Nos. ____________________________________________
Permenant Address (INDIA):_______________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Bank Account Details ( in INDIA ) :_________________________ Bank Account Details ( Overseas ) :
Bank Account No.: ________________________________________ Bank Account No.: _________________________________________________
Name of the Bank & Address : ___________________________ Name of the Bank & Address : ___________________________________
__________________________________________________________________________________________________________________
______________________________________________________ BSB Code :_______________________________________
IBAN No. :
Email Id :______________________________________________________________________________________
Date of Birth: ______/______/_______ Sex: M / F M
Assistance Company Ref No.: _______________________________ Passport No.: __________________________________________
Date of Departure: ___/___/___ Flight No. _________ From __________________ to ____________________
Date of Arrival: ___/___/___ Flight No. _________ From __________________ t to
MEDICAL ACCIDENT & SICKNESS BENEFIT
If accident, details of accident i.e. how, when, where it took place:________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Date:_________________________________________Place: ______________________________________________________________
If sickness, state nature and diagnosis, and advise when & where symptoms first occurred: __________________________________________
___________________________________________________________________________________________________________________
Date:_________________________________ Place: ______________________________________________________________
Name & Address of consulting physician: _________________________________________________________________________________

____________________________________________________________________________________________________________________
Have you ever been treated for this illness before: Yes No
If yes, provide name & address of consulted physician: _______________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Provide name & address of your family physician: ___________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Provide name of any prescription medicine you are presently taking: ____________________________________________
Indicate other health insurance coverages, including name, address, policy number & certificate number of insurer:
AUTHORIZATION

I hereby authorize any hospital, physician, or other person who has attended or examined me, to furnish to the company,
or its authorized representative, any and all information with respect to any illness or injury, medical history, consultation,
prescriptions or treatment and copies of all hospital or medical records, a photostat copy of this authorization shall be
considered as effective and valid as the original.

Date: Place:

Signature of insured :_____________________________________________________________________________________

DETAILS OF MEDICAL EXPENSES
Details of treatment In/ Out Patient Charges (Currency) Status of Payment
From To AUD Paid/ Outstanding

Paid
Outstanding
'TOTAL
Whether Assistance Co. was contacted: Yes No. If Yes, Reference No. __________________________
If No, give reasons:_____________________________________________________________________________________
_________

Attending Doctor's Report

Patient's Name: ____________________________________________________ Age: _______ Sex: M/F

Address: ____________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Date contacted: __________________________________ Time: __________________________

For Accidental Injury

Nature of Injury: ______________________________________________________________________________________
____________________________________________________________________________________________________
X-Ray Taken: Yes No Date taken: ____________________________________
Diagnosis and Treatment Given: __________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Describe any other disease or infirmity affecting present condition: ______________________________________________

For Sickness
Nature of Illness: ______________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Diagnosis and Treatment Given: __________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
When did patient's symptoms first appear: _________________________________________________________________
Describe any other disease or informity affecting present condition: _____________________________________________
____________________________________________________________________________________________________
Is condition due to Pregnancy: Yes No Is illness due to any pre-existing condition: Yes No

Signature:_________________________________________________
Attending Doctor's Signature

LOSS/DELAY OF CHECKED BAGGAGE

Describe when & where the loss/delay took place: ___________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
State the extent of Loss: ________________________________________________________________________________
Name the common carrier: ___________________________
1. Flight No. ___________________ From _______________________________ to _______________________________
2. Flight No. ___________________ From _______________________________ to _______________________________
Has the common carrier been notified at the time of loss? Yes No Airline Reference No. _________________
Details of compensation received from carrier: _______________________________________________________________
Scheduled date/time of Arrival:___/___/____; __:__hrs. Actual date/time when bags delivered :___/___/____; __:__hrs
No. of Hours delayed :__________
Item Purchased/Lost * Date of Purchase Place Cost
 TOTAL
Less Compensation received from Airline:
Net Amount:
* In case of Delay, please provide details of purchases made
* In case of Loss, please provide details of items lost.

LOSS OF PASSPORT
Please provide details of the incident i.e. when, where and how it happened:_______________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Details of Police Report (please attach copy): No:_____________________Date: ___________ Place: ________________
Details of Expense incurred Date Place Amount

TOTAL

TRAVEL DELAY
Flight No. ________________ Date____/____/______ From _______________________ to________________________
Scheduled time of Departure:___________ Actual time of Departure: ____________ No. of Hours delayed:____________
Whether accomodation & boarding provided by carrier: Yes No
Details of Expense incurred Date Place Amount

TOTAL