TRAVEL INSURANCE REPORT FORM

QUEENSLAND UNIVERSITIES

TRAVEL INSURANCE REPORT FORM

1. This form must be fully completed in the sections applicable to your claim and signed.

2. The Privacy Consent section must also be signed for all claims.

3. For baggage/business property, electronic equipment and money/travel documents claims - attach invoices, valuations or receipts to support the value of the items being claimed and, most important, written confirmation from the police, Local Government or Carrier supporting your notification of the loss (if applicable).

4. For medical claims – enclose all the relevant documents to support your claim. Medical reports may be necessary, therefore the Medical Authority on this form must also be signed and completed by you.

5. For damage or loss by the carrier, cancellation and curtailment, loss of deposits or additional expenses claims – obtain written advice from the carrier involved as to the amount of the refund obtainable from them as a result of the damage or loss of articles, cancellation or curtailment of the journey, loss of deposits or additional expenses.

The issue of this form is not an admission of liability or a waiver of rights and is without prejudice.

ALL QUESTIONS IN THIS SECTION MUST BE ANSWERED

Name of Traveller (Mr/Mrs/Miss/Ms): ___________________________________________________________________________

Occupation: _______________________________ Date of Birth: ___________________

Address: _____________________________________________ Email (Important):_________________________________

Telephone: Home: ___________________ Business: __________________ Mobile:______________________

Full Policy No. and Prefix: ________________ _________________________________ _____________________

TRAVEL INFORMATION AND AUTHORISATION

Country or Countries Visited ____________________________________________________________________________________

Date of Departure ____________ Date of Return ____________ Was an air trip involved in the travel? __________________

Please Print and Sign Name (Company Representative)* _____________________________________________________________

Position Held (Company Representative)* _____________________________________________________

Is the above noted Travel an Authorized Business Trip (Company Representative)*? ___________________

*These sections may only be filled out by an authorised company representative (i.e. Person who authorised your travel).

ELECTRONIC FUNDS TRANSFER DETAILS

Following approval of your claim, your claim benefits will be transferred directly into your bank account. Please provide the following details:

Ž Bank Draft in the following currency _________ , or;

Ž Direct to Bank Account Details Below:

Bank/Financial Institution: ____________________________ Address: _____________________________________________

Account Name: _____________________________________________________________________________________________

BSB Number: _______________________________________ Account Number: ________________________________________

SWIFT: ____________________________________________

PRIVACY CONSENT, INFORMATION AUTHORITY AND WARRANTY
We have always valued your privacy. From 21 December 2001 we are bound by the Privacy Act 1988 when we collect and handle your personal information. About your information Corporate Services Network (CSN) is an outsourcing processing claims centre and we collect personal information that is necessary to provide and manage our service, as a third party administration and claims processing centre to our clients. We disclose personal information to third parties when necessary to assist us and them in providing and managing this service. This may include agents, brokers, contractors, insurers, reinsurers, loss assessors, medical practitioners, insurance intermediaries, insurance reference bureaus, credit reference agencies, our and your advisers, persons involved in the claims handling process, Government authorities, courts, tribunals or other dispute resolution bodies. We limit the use and disclosure of any personal information provided by us, to them, to the specific purpose for which we supplied it. You authorise Corporate Services Network to collect, use and disclose your personal information for these purposes. You also give express authority for Corporate Services Network to, where applicable collect, use and disclose your personal information that amounts to sensitive information under the Act, as required to provide and manage the relevant product or service. If you do not agree to the above we may not be able to provide you with our services. If you wish to request access or correction to the information we hold about you, opt out of receiving materials we send or request a copy of our privacy policy then contact the Privacy Manager, Corporate Services Network Pty Ltd, Level 2, 280 George Street, Sydney 2000. I/we understand and agree to the above.
Date:_______________________________________	Signature:_______________________________________

BAGGAGE/BUSINESS PROPERTY, ELECTRONIC EQUIPMENT, DEPRIVATION OF BAGGAGE AND MONEY/TRAVEL DOCUMENTS CLAIM
Give full details of how losses, damage or thefts occurred : (Detail each event)
Date loss/damage occurred / /			Time am/pm		Date loss/damage reported / /					Time am/pm
Loss/damage reported to – (Police, Airline or other authority) Name
Were articles lost/damaged by Carrier? (e.g. Airline) Yes/No If yes, Name of Carrier:
Have you yet lodged a claim or complaint against any Carrier/Airline or other Authority or against any individual responsible for the loss or damage to your property? If so, give details and attach copies of correspondence. NOTE: The Warsaw Convention imposes a liability upon the Carrier and you should claim on them first					Airline:				Claim No.
What Action was taken to recover lost items?
Are any of the items covered by other insurance? Yes/No If Yes, - which company Policy Number
Were all the missing articles your property? Yes/No If no, give details
Other comments (if necessary)
Description and size of suitcase in which missing goods carried
Full details of articles claimed (include value of cases)	Name and address from whom goods were purchased			Original Date of Purchase		Original Purchase Price	Deduction for Depreciation	Amount Claimed (specify Currency)			Remarks

THE FOLLOWING ITEMS MUST BE INCLUDED WITH THIS CLAIM:

1. Report or letter from Authority (eg. Police, Airline) regarding the loss, where available.

2. Proof of purchase of lost goods (eg. Receipts, Guarantee or Valuation Certificates, Card Vouchers, etc.)

Failure to provide these items may result in delays in processing your claim. It if is impossible to provide any of the supporting documents please advise the reason.

PERSONAL ACCIDENT & SICKNESS (INCLUDING DENTAL) AND MEDICAL & ADDITIONAL EXPENSES CLAIM
Type of Injury or Sickness		Date of Accident or Commencement of Sickness
If Injury – Give full details of Accident
Date of First Medical Consultation	Name of Doctor or Hospital
Details of other treatment by Doctors/Hospital
Dates in Hospital	Admitted / / am/pm Discharged / / am/pm
List the Country and the currency of the Country in which you incurred the medical costs	Country: Currency: Total Amount
	Country: Currency: Total Amount
Have you ever suffered from the same or similar complaint in the past?	Yes / No
If Yes, give details, dates, names and addresses of treating physicians
Name and address of usual treating doctor.
How long has the doctor been known to the patient?
Are you a member of a private health insurance fund (eg. Medibank).	Yes / No Name of fund:

PLEASE NOTE: All medical accounts must first be lodged with your private health fund, if applicable.

THE FOLLOWING ITEMS MUST BE INCLUDED WITH THIS CLAIM:

1. Original Doctor/Hospital accounts and receipts together with statements from Medicare and Private Health Funds.

2. Original Doctor’s certificate

Failure to provide these items may result in delays in processing your claim. It if is impossible to provide any of the supporting documents please advise the reason.

CANCELLATION AND CURTAILMENT EXPENSES, LOSS OF DEPOSITS CLAIM
What was the reason you could not commence or complete your proposed journey?
Was the cancellation as a result of Injury/Sickness to yourself? Yes/No
Was the cancellation as a result of Injury/Sickness to some other relative or person as defined in the Policy? Yes/No
If Yes : Name Address Relationship Age
Nature of complaint preventing travel
Date you advised Travel Agent to cancel bookings		/ /
Amount of Deposit paid and date paid		$ Date
Balance of Full Fare and date paid		$ Date
Value of Fortified Portion of Journey (if applicable)		$
Refund received on cancellation		$
Full amount being claimed		$
Were any alternative arrangements offered? If so, give details
Did you accept any of the alternative arrangements? Yes/No
What additional fares did you incur as a result of the arrangement?

~ You will also need to fill out the Missed Transport, Cancellation & Curtailment Claim section on the following page.

THE FOLLOWING ITEMS MUST BE INCLUDED WITH THIS CLAIM:

1. Original receipts and/or Tickets relating to additional expenses incurred.

2. Proof of cause ie. Original Doctor/Hospital certificate relating to Injured or Sick person or letter relating to cancellation, curtailment or diversion of scheduled public transport.

Failure to provide these items may result in delays in processing your claim. It if is impossible to provide any of the supporting documents please advise the reason.

PERSONAL LIABILITY CLAIM
Bodily Injury – Provide relevant details – Name Address of injured Party and details of Injury
Damage to Property – List all Property Damage together with Name and Address or Party claiming damage against you
Is the Injury or Damage related to a travelling companion? Yes/No
Do you consider you were at fault? Yes/No If so, why

THE FOLLOWING ITEMS MUST BE INCLUDED WITH THIS CLAIM:

1. Letter or document of a claim made on you.

Failure to provide these items may result in delays in processing your claim. It if is impossible to provide any of the supporting documents please advise the reason.

MISSED TRANSPORT, CANCELLATION & CURTAILMENT CLAIM (For additional travel and accommodation incurred during the journey)
Reason for incurring additional travel or accommodation expenses
List the Country and the Currency of the Country in which you incurred the costs	Country: Currency:
List specifically the additional TRAVEL expenses	Details		Amount
			A$
			A$
			A$
			A$
	TOTAL		A$
List Specifically the additional ACCOMMODATION expenses	Details		Amount
			A$
			A$
			A$
			A$
	TOTAL		A$
Were these expenses incurred as a result of Injury or Sickness as claimed in Part 1? Yes/No
If these expenses were incurred as a result of Injury or Sickness to any other person, please give details of cause, name, address, age of person and relationship to you		Name		Age
		Address	Relationship
Cause

THE FOLLOWING ITEMS MUST BE INCLUDED WITH THIS CLAIM:

1. Receipts and/or tickets relating to additional expenses incurred.

2. Doctor/Hospital certificate specifying exact nature of condition suffered by injured/sick person.

3. Letter from the travel agent or carrier verifying reason for additional expenses and/or any refund applicable.

Failure to provide these items may result in delays in processing your claim. It if is impossible to provide any of the supporting documents please advise the reason.

RENTAL VEHICLE EXCESS WAIVER CLAIM

Please provide a full description of the circumstances of the incident giving rise to the claim:

THE FOLLOWING ITEMS MUST BE INCLUDED WITH THIS CLAIM:

1. The Rental Agreement.

2. Notice from the Rental Company in respect of the excess or deductible.

3. Documentation evidencing payment of excess or deductible.

Failure to provide these items may result in delays in processing your claim. It if is impossible to provide any of the supporting documents please advise the reason.

PERSONAL ACCIDENT & SICKNESS – ACCIDENTAL DEATH CLAIM
What was the cause of death?
When did the accident occur?		Time am/pm
Was a coronial inquest held or is one to be held? Yes/No If yes, give details
Place where inquest held

THE FOLLOWING ITEMS MUST BE INCLUDED WITH THIS CLAIM:

1. The original policy document.

2. Original of the death certificate which will be returned to you.

3. Copy of the Coroner’s depositions and findings (if applicable).

4. Original birth certificate which will be returned to you

Failure to provide these items may result in delays in processing your claim. It if is impossible to provide any of the supporting documents please advise the reason.