FORMULIR KLAIM ASURANSI PERJALANAN

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FORMULIR KLAIM ASURANSI PERJALANAN

Tujuan dari dokumen ini adalah untuk membantu Anda melengkapi pengajuan klaim asuransi Anda.

Silakan baca petunjuk di bawah ini dan ikuti dengan saksama agar kami dapat menilai pengajuan klaim Anda dengan lebih cepat.

Halaman pertama ini hanya untuk informasi Anda. Anda tidak perlu mengirimkan halaman ini bersama pengajuan klaim Anda.

Agar kami dapat melakukan proses akseptasi atas klaim yang Anda ajukan:

 Anda harus memberikan seluruh informasi pribadi Anda termasuk nomor polis, nama lengkap, dan alamat email.

 Anda harus menyertakan salinan paspor Anda, dan paspor mereka yang mengajukan klaim.

 Anda harus memberikan informasi rekening bank Anda untuk tujuan pembayaran.

 Anda harus mencantumkan jumlah total (uang) dari klaim Anda.

 Hanya lengkapi bagian(-bagian) yang berlaku untuk klaim Anda.

 Pastikan seluruh bagian telah diisi secara lengkap.

 Jika Anda mengajukan klaim lebih dari satu manfaat polis, mohon lengkapi setiap bagian yang diperlukan.

 Jika ruang isian yang disediakan tidak cukup, mohon lampirkan surat yang berisi informasi tambahan.

 Setiap bagian memerlukan dokumen tertentu yang dicantumkan di bawah judul bagian. Mohon lampirkan semua dokumen tersebut bersama formulir klaim Anda.

 Jika Anda mengajukan klaim untuk Bagasi dan Harta Pribadi, mohon pastikan Anda menyertakan faktur asli atau bukti kepemilikan lainnya yang sesuai

 Jika Anda tidak dapat menyertakan salah satu dokumen yang disyaratkan, mohon jelaskan alasannya agar kami dapat mempertimbangkan untuk melanjutkan/tidak melanjutkan proses akseptasi atas klaim yang Anda ajukan. Jika salah satu informasi di atas tidak lengkap, maka proses akseptasi klaim Anda dapat dihentikan.

Setelah seluruhnya dilengkapi, tanda tangani formulir klaim, lampirkan dokumen yang dibutuhkan/tambahan, dan kirimkan semuanya dalam satu amplop. Jika dikirimkan secara terpisah, dokumen Anda kemungkinan akan terpencar sehingga mengakibatkan penundaan atas proses akseptasi klaim Anda.

Kirimkan formulir klaim yang telah dilengkapi dan/atau dokumen tambahan yang diperlukan untuk mendukung klaim Anda ke:

1. Kirimkan formulir klaim dan dokumen Anda melalui email ke SimasNet-claims@covermore.co.id

ATAU

2. Kirimkan formulir klaim dan dokumen Anda melalui pos ke alamat PT. Asuransi Simas Net

Plaza Simas Lt. 7

Jl. KH Fachrudin No. 18. Tanah Abang – Jakarta 10250 INDONESIA

Jika Anda mempunyai pertanyaan atau kurang yakin akan sesuatu hal, silakan hubungi staf pusat panggilan kami melalui nomor telepon yang tercantum dalam policy wording Anda.

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FORMULIR KLAIM ASURANSI PERJALANAN

Untuk melengkapi formulir klaim ini dengan akurat:

 Mohon baca formulir klaim dengan saksama.

 Lengkapi SEMUA langkah-langkah.

 Gunakan huruf KAPITAL.

 Simpan salinan dari seluruh dokumen yang Anda kirimkan untuk arsip Anda.

 Jika diperlukan, kami mungkin akan meminta pengiriman faktur, laporan, atau dokumentasi asli lainnya.

 Dokumen dalam bahasa asing harus diterjemahkan ke dalam bahasa Inggris dengan biaya Anda sendiri.

 Mohon merujuk pada persyaratan dokumentasi yang ditetapkan untuk masing-masing bagian. Mohon diperhatikan:

 Karena sifat setiap klaim berbeda, informasi lebih lanjut (di luar yang telah dinyatakan dalam formulir klaim) mungkin akan diminta.

 Mohon sertakan fotokopi halaman identitas dari paspor Anda yang berlaku saat ini.

 Mohon sertakan fotocopy sertifikat asuransi Anda.

 Jika bagian dari klaim ini terdapat unsur penipuan, klaim Anda akan ditolak dan dapat dilaporkan ke pihak yang berwenang.

DETAIL PRIBADI

1. Nomor polis asuransi: _____________________________________________________________________________________________ 2. Nama pemegang polis (sesuai dengan sertifikat asuransi) mohon garis bawahi nama keluarga/belakang Anda: ( ) Bapak ( ) Ibu ________________________________________________Tanggal Lahir: _____/_____/_____

3. Nama pengaju klaim. Mohon garis bawahi nama keluarga/belakang Anda:

( ) Bapak ( ) Ibu ( ) Anak ________________________________________________Tanggal Lahir: _____/_____/_____

4. Alamat rumah: _______________________________________________________________________________________________________ _________________________________________________________________________________________Kode pos: _____________________ 5. Telepon rumah: __________________________ Telepon seluler: ____________________________________

6. Alamat email (mohon tuliskan dengan jelas karena seluruh korespondensi akan dikirimkan ke alamat ini):

_________________________________________________________________________________________________________________________ 7. Tujuan perjalanan: ___________________________________________________________________________________________________ 8. Apakah Anda membayar rencana perjalanan Anda menggunakan kartu kredit? ( ) Ya ( ) Tidak

Jika ya, mohon lengkapi yang berikut ini:

Penerbit kartu kredit (misalnya, Maybank) ____________________________Jenis kartu (misalnya, Visa): ______________________ Status Kartu: Gold ( ) Silver ( ) Lainnya: __________________________________________________________________________________ 9. Apakah Anda memiliki perlindungan asuransi perjalanan dari kartu kredit Anda? ( ) Ya ( ) Tidak

Jika ya, apakah Anda telah mengajukan klaim atas kejadian ini? ( ) Ya ( ) Tidak

10. Apakah ada asuransi lain yang memberikan perlindungan atas kehilangan ini, seperti asuransi rumah beserta isinya, kesehatan, atau mobil?

Jika ya, mohon tuliskan perinciannya, termasuk nomor polis: ____________________________________________________________

INFORMASI KLAIM

Di bagian ini, Anda diminta untuk melengkapi keadaan klaim Anda. Mohon beri tanda centang pada bagian yang Anda klaim. ( ) 1. Klaim Biaya-Biaya Perawatan Medis Dan Gigi Di Luar Negeri

( ) 2. Klaim Bagasi dan Harta Pribadi

( ) 3. Keterlambatan Perjalanan atau Bagasi/Ketidaksinambungan Dalam Penerbangan ( ) 4. Klaim Pembatalan

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Bagian 1: Klaim Biaya-Biaya Perawatan Medis Dan Gigi Di Luar Negeri

Mohon lampirkan seluruh dokumen berikut yang terkait dengan klaim Anda:

 Faktur/tanda terima terperinci termasuk biaya yang timbul dan uraian dari masing-masing biaya.

 Seluruh laporan medis termasuk perincian lengkap mengenai penyakit/cedera.

 Mohon lengkapi sertifikat medis terlampir (halaman terakhir).

 Kecuali dianggap sebagai peristiwa minor, kami tidak dapat memproses klaim Anda tanpa sertifikat medis yang lengkap.

 Kami mungkin masih memerlukan dokumen/informasi tambahan. Jika hal itu terjadi, kami akan secara khusus memintanya kepada Anda.

1. Nama pasien yang mengalami sakit/cedera: ______________________________________________________________________ 2. Hubungan pasien dengan pemegang polis: ________________________________________________________________________ 3. Jenis penyakit/cedera: ___________________________________________________________________________________________ 4. Tanggal pertama kali penyakit/cedera dialami: ____/____/____

5. Bagaimana penyakit/cedera terjadi? _________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ 6. Apakah pasien pernah mengalami penyakit/cedera yang sama/serupa sebelumnya? ( ) Ya ( ) Tidak

Jika ya, mohon berikan perincian termasuk tanggal: _____________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ 7. Nama dan nomor telepon dokter yang biasa dikunjungi pasien: ______________________________________________________ _________________________________________________________________________________________________________________________ 8. Negara tempat perawatan dilakukan _________________________________________________________________________________ Mohon cantumkan masing-masing faktur/kuitansi secara terpisah dalam tabel di bawah ini:

Nama Dokter/Rumah Sakit Perawatan Tanggal Perawatan _{Jumlah Ditagih} _Dibayar?

misalnya, Dr Tran misalnya, Konsultasi misalnya, 15/02/2015 _{misalnya, $350 USD} _Ya

Biaya akan dikonversikan ke mata uang negara Anda menggunakan kurs pada tanggal biaya tersebut muncul.

Bagian 2: Klaim Bagasi dan Harta Pribadi

 Faktur atau bukti lain yang menunjukkan kepemilikan atas barang yang diklaim.

 Jika Anda mengajukan klaim atas kerusakan barang, mohon berikan biaya perbaikan.

 Laporan kehilangan dari pihak berwenang yang menerima laporan kehilangan Anda: misalnya, Laporan Polisi, Hotel, atau Maskapai Penerbangan

 Jika berlaku, surat dari perusahaan angkutan yang menguraikan kompensasi yang dibayarkan kepada Anda.

 Tiket perjalanan dan label bagasi Anda.

1. Tanggal kejadian: ____/____/____ 2. Waktu: ______________ 3. Lokasi & negara: ________________________________________ 4. Mohon jelaskan kejadiannya (lampirkan halaman terpisah jika ruang yang disediakan tidak cukup): __________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ 5. Apakah Anda telah mengajukan atau menerima kompensasi? Jika ya, mohon berikan perincian mengenai pihak pembayar dan jumlahnya: _______________________________________________________________________________________________ 6. Apakah Anda melaporkan kejadian ini kepada polisi? ( ) Ya ( ) Tidak Jika ya, mohon lampirkan laporan polisi

7. Mohon isi tabel di bawah ini secara lengkap:

Barang Tanggal Pembelian Tempat Pembelian Jumlah Dibayarkan Jumlah Diklaim misalnya, Kamera misalnya, 22/11/2014 misalnya, Jakarta misalnya, Rp3.000.000 misalnya, Rp3.000.000

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Bagian 3: Klaim Keterlambatan Perjalanan atau Bagasi/Ketidaksinambungan Dalam

Penerbangan

 Pernyataan tertulis dari maskapai penerbangan yang mengonfirmasi durasi dan alasan keterlambatan.

 Mohon tuliskan jika Anda telah menerima kompensasi dari maskapai penerbangan termasuk perjalanan, makanan, atau akomodasi.

 Komunikasi apa pun yang diterima dari maskapai penerbangan terkait keterlambatan.

 Jika anda ingin mengklaim keterlambatan bagasi, mohon pastikan bahwa anda menyediakan tanda bukti pembelian yang asli atau bukti yang sesuai dari pembelian yang diperlukan, seperti pakaian dan perlengkapan mandi.

Detail Penerbangan Awal Detail Keterlambatan Penerbangan/Bagasi

Tanggal keberangkatan: Tanggal keberangkatan/kembali bagasi:

Waktu keberangkatan: Waktu keberangkatan/kembali bagasi:

Tempat keberangkatan: Tempat keberangkatan:

Nomor penerbangan: Nomor penerbangan:

Maskapai penerbangan: Maskapai penerbangan:

Informasi lain (jika diperlukan):

_________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________

Bagian 4: Klaim Pembatalan

 Surat dari agen perjalanan Anda yang mengonfirmasikan seluruh biaya pembatalan.

 Surat dari agen perjalanan Anda yang mengonfirmasikan jumlah total yang dibayarkan dan jumlah total yang telah/akan dikembalikan.

 Syarat dan ketentuan untuk semua rencana perjalanan Anda.

 Seluruh dokumentasi yang mendukung alasan pembatalan Anda.

 Jika perjalanan Anda dibatalkan karena alasan kematian, mohon lampirkan surat keterangan kematian. 1. Tanggal Anda membatalkan/mengubah perjalanan Anda: ____/____/____

2. Tanggal peristiwa yang menyebabkan pembatalan/perubahan: ____/____/____ 3. Apakah ini karena alasan medis? ( ) Ya ( ) Tidak

Jika ya, mohon minta kepada dokter yang menyarankan pembatalan untuk melengkapi sertifikat medis terlampir (halaman terakhir).

4. (Jika berlaku) Nama orang yang sakit/cedera: _________________________________________________________________ 5. Uraian penyakit/cedera: _________________________________________________________________________________________ 6. Apakah orang yang sakit/cedera pernah mengalami penyakit/cedera yang sama/serupa sebelumnya? ( ) Ya ( ) Tidak 7. Tanggal Anda memesan perjalanan Anda: ____/____/____ 8. Tanggal Anda membatalkan perjalanan: ____/____/____ 9. Penjelasan lebih lengkap alasan Anda membatalkan/mengubah perjalanan Anda:

_____________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________

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5 10. Mohon cantumkan masing-masing item pada tabel di bawah ini:

Uraian Tanggal Pembelian Tempat Pembelian Jumlah Dibayarkan Dikurangi

Pengembalian Dana Jumlah Diklaim

misalnya, Penerbangan misalnya, 15/05/2015 misalnya, Jakarta misalnya, $1300-$100 USD misalnya, $1.200 USD

Bagian 5: Klaim Lain (Alasan Lain untuk Pengajuan Klaim)

 Setiap dokumen yang terkait dengan penyebab pengajuan klaim yang akan diperlukan untuk melakukan penilaian.

 Mohon berikan informasi sebanyak mungkin, termasuk surat-surat atau faktur-faktur tambahan, dll.

Mohon jelaskan peristiwa yang menyebabkan pengajuan klaim ini secara terperinci. Jika ruang yang disediakan tidak cukup, mohon tuliskan dan lampirkan pada halaman yang terpisah.

_________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ Mohon konfirmasikan jumlah yang dibayarkan dan tanggal-tanggal penting:

________________________________________________________________________

_________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________

PENGIRIMAN FORMULIR KLAIM

Saya/Kami menyatakan bahwa formulir klaim ini telah diisi secara lengkap dan seluruh informasi yang tersedia dan diperlukan telah dilampirkan.

Saya/Kami menyatakan bahwa informasi yang diberikan adalah benar dan tidak ada informasi yang disembunyikan. Saya/Kami memahami bahwa klaim ini akan ditolak jika bagian yang terkandung di dalamnya adalah palsu, tidak akurat dengan sengaja, atau ada informasi yang disembunyikan.

Saya/Kami memahami bahwa jika klaim ini mengandung unsur penipuan, maka akan dilaporkan kepada pihak yang berwajib.

Saya/Kami menyetujui atas pengumpulan, penggunaan, dan pengungkapan informasi pribadi untuk tujuan pemrosesan klaim ini.

Nama (HURUF CETAK): ________________________________________________________________________________________________ Tanda tangan: __________________________________________________________________ Tanggal: ______________________________

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PERINCIAN PEMBAYARAN

Seluruh pembayaran atas klaim yang disetujui akan disetorkan secara langsung ke rekening bank Anda. Jika Anda tidak mencantumkan informasi bank, kami tidak dapat melakukan pembayaran kepada Anda.

Nama Bank: __________________________________________________________________________________________________

Alamat Bank: ________________________________________________________________________________________________

Kode SWIFT Bank: ____________________________________________________________________________________________

Nama Penerima: ____________________________________________________________________________________________

Alamat Penerima: __________________________________________________________________________________________

Nomor telepon penerima: ___________________________________________________________________________________

Nomor Rekening: _______________________

____________________________________________________________________________ irimkan formulir klaim yang telah dilengkapi dan/atau dokumen tambahan yang diperlukan untuk mendukung klaim Anda ke:

1. Kirimkan formulir klaim dan dokumen Anda melalui email ke SimasNet-claims@covermore.co.id

ATAU

2. Kirimkan formulir klaim dan dokumen Anda melalui pos ke alamat PT. Asuransi Simas Net

Plaza Simas Lt. 7

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SERTIFIKAT MEDIS

Formulir ini wajib dilengkapi oleh dokter yang menangani pasien atas klaim yang disebabkan oleh kecelakaan, penyakit, atau kematian. Biaya atas pembuatan sertifikat ini ditanggung oleh pemegang polis.

Nama pasien: ____________________________________________________________________ Tanggal Lahir: ____/____/____ Mohon lengkapi sertifikat ini dengan huruf kapital dan berikan informasi selengkap mungkin. Terima kasih atas kerja sama Anda.

1. Apakah Anda dokter yang menangani pasien ini? _______________________________________________________________ 2. Jika bukan, apakah Anda memiliki akses ke rekam medisnya? _________________________________________________________ Mohon hanya menjawab pertanyaan 3 atau 4. Pengaju klaim akan menunjukkan pertanyaan yang sesuai.

3. Pembatalan atau pengubahan rencana perjalanan sebelum keberangkatan.

(a) Apakah Anda menyarankan pasien untuk membatalkan/menunda perjalanan karena kondisi kesehatannya? _________ (b) Mohon jelaskan secara terperinci mengenai penyakit atau cedera (termasuk diagnosis akhir): _______________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ (c) Pada tanggal berapa Anda menyarankan bahwa perjalanan seharusnya dibatalkan? ____/____/____

(d) Pada tanggal berapa pasien pertama kali sadar akan gejala yang timbul? ____/____/____

(e) Pada tanggal berapa Anda pertama kali mengetahui kondisi, atau perubahan kondisi ini? ____/____/____

(f) Apakah pasien ini sebelumnya pernah diperiksa, didiagnosis, atau dirawat sehubungan dengan penyakit atau cedera yang sama/serupa/terkait? _____________________________________________________________________________________________ (g) Jika ya, mohon jelaskan secara terperinci dari riwayat pasien (misalnya, tanggal kecelakaan, saran, perawatan, pengobatan):____________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ (h) Apakah rencana perjalanan yang dipesan bertentangan dengan saran Anda, atau saran dari profesional medis lainnya? ________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________

ATAU

4. Biaya perawatan medis atau biaya tambahan yang timbul selama perjalanan.

(a) Apa yang Anda pahami terkait penyakit atau cedera yang mengakibatkan perlunya penanganan medis atau

penyesuaian rencana perjalanan pasien? ________________________________________________________________________________ (b) Apakah pasien ini sebelumnya pernah diperiksa, didiagnosis, atau dirawat sehubungan dengan penyakit atau cedera yang sama/serupa/terkait? ______________________________________________________________________________________________ (c) Jika ya, mohon jelaskan secara terperinci dari riwayat pasien (misalnya, tanggal kecelakaan, saran, perawatan,

pengobatan):____________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ (d) Sebelum keberangkatan, apakah ada indikasi bahwa perawatan medis kemungkinan diperlukan? ___________________ (e) Apakah pasien tidak mematuhi saran medis saat sebelum atau selama perjalanan? __________________________________ _________________________________________________________________________________________________________________________ (f) Apakah perjalanan pasien bertentangan dengan saran Anda, atau saran dari profesional medis lainnya? _____________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ Saya menyatakan bahwa pernyataan yang terkandung dalam sertifikat medis ini adalah benar dan tepat.

Tanda tangan dokter: ____________________________________________________________Tanggal:____/____/____ Cap Dokter:

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TRAVEL INSURANCE CLAIM FORM

This purpose of this document is to help you complete your insurance claim.

Please read the instructions below and carefully follow them, this will enable us to complete the assessment of your claim much faster.

This first page is for your information only. You do not need to submit this page with your claim. To enable us to assess your claim:

 You must provide all of your personal details including your policy number, full name and email address.

 You must provide a copy of your passport, and the passport of those who are claiming.

 You must provide your bank account details for payment purposes.

 You must list the total amount (in money) of your claim.

 Only complete the section(s) that apply to your claim.

 Please ensure that the entire section is completed.

 If you are claiming more than one policy benefit, please complete each section as required.

 If you do not have enough space to write and require more, please attach a letter with the additional information.

 Each section requires specific documents, these are listed under the section heading. Please submit all of these documents with your claim form.

 If you are claiming for Luggage and Personal Effects, please ensure that you supply original receipts or other suitable proof of ownership

 If you are unable to supply one of the required documents, please explain why so that we may consider how to progress with your claim.

If any of the above information is missing we may not be able to assess your claim.

Once all of the above is completed, please sign the claim form, attach your required/additional documents and submit everything together. If your documents are sent separately they may get lost, resulting in a delay assessing your claim. Please send the completed claim form and/or any additional documents to support your claim to:

1. Email your claim form and documents to SimasNet-claims@covermore.co.id

OR

2. Mail your claim form and documents to PT. Asuransi Simas Net

Plaza Simas Lt. 7

If you have any questions or you are unsure of anything, please contact our call centre staff via the telephone number supplied with your policy wording.

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TRAVEL INSURANCE CLAIM FORM

To accurately complete this claim form:

 Please read the claim form carefully

 Complete ALL steps.

 Use CAPITAL letters.

 For your records, keep a copy of every document that you submit.

 If required we may request the submission of original receipts, reports or other documentation.

 Documents in a foreign language are required to be translated into English at your own expense.

 Please refer to the specified documentation requirements for each section. Please note:

 As each claim is different, further information (beyond that stated on the claim form) may be requested.

 Please include a photocopy or scan of the ID page of your current, valid passport.

 Please supply a copy of your certificate of insurance.

 If any part of the claim is found to be fraudulent, your claim will be denied and may be referred to the appropriate authorities.

PERSONAL DETAILS

1. Insurance policy number: _____________________________________________________________________________________________ 2. Name of policy holder (as per the certificate of insurance) please underline your family/last name:

( ) Mr ( ) Mrs ( ) Miss ( ) Ms ( ) Dr _________________________________________________________Date of Birth: _____/_____/_____ 3. Name of the person making the claim. Please underline your family/last name:

( ) Mr ( ) Mrs ( ) Miss ( ) Ms ( ) Dr _________________________________________________________Date of Birth: _____/_____/_____ 4. Home address: _______________________________________________________________________________________________________ _________________________________________________________________________________________Postcode: _____________________ 5. Home telephone: __________________________ Mobile telephone: ____________________________________

6. Email address (please write clearly as all correspondence will be sent to this address):

_________________________________________________________________________________________________________________________ 7. Travel destination: ___________________________________________________________________________________________________ 8. Did you pay for your travel arrangements using a credit card? ( ) Yes ( ) No If yes, please complete the following: Credit card provider (e.g. Maybank) _______________________________Card type (e.g. Visa): _______________________________ Card Status: Gold ( ) Silver ( ) Other: ____________________________________________________________________________________ 9. Do you have travel insurance coverage under your credit card? ( ) Yes ( ) No

If yes, have you made a claim against this? ( ) Yes ( ) No

10. Is there any other insurance covering this loss, such as home and contents, medical or car insurance?

If yes, please provide details including policy number: __________________________________________________________________

CLAIM INFORMATION

In this section you will be required to complete the circumstances of your claim. Please tick the section that you are claiming. ( ) 1. Overseas Medical and Dental Expenses Claim

( ) 2. Luggage and Personal Effects Claim

( ) 3. Travel or Baggage Delay /Flight Misconnection ( ) 4. Cancellation Claim

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Section 1: Overseas Medical and Dental Expenses Claim

Please provide all of the following documents relating to your claim:

 Itemised receipts/accounts including the costs incurred and a description of each cost.

 Any and all medical reports including full details of the illness/injury.

 Please complete the attached medical certificate (last page).

 Unless it is considered a minor event we cannot process your claim without a completed medical certificate.

 We may still require additional documents/information. If so, we will specifically request them.

1. Name of the patient who incurred illness/injury: ______________________________________________________________________ 2. The patient’s relationship to the policy holder: ________________________________________________________________________ 3. Nature of the illness/injury: ___________________________________________________________________________________________ 4. Date the illness/injury first occurred: ____/____/____

5. How did the illness/injury occur? _____________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ 6. Has the patient person suffered from the same/similar illness/injury before? ( ) Yes ( ) No

If yes, please provide details including dates: ____________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ 7. Name and phone number of patient’s usual Doctor: __________________________________________________________________ _________________________________________________________________________________________________________________________ 8. Country of treatment _________________________________________________________________________________________________ Please list each receipt/bill separately in the table below:

Name of Doctor/Hospital Treatment Date of

Treatment Amount Charged Paid?

e.g. Dr Tran e.g. Consultation e.g. 15/02/2015 e.g. $350 USD Yes

Costs will be converted to your relevant currency using the exchange rate from the date the costs were incurred.

Section 2: Luggage and Personal Effects Claim

 Receipts or other proof of ownership for the claimed items.

 If you are claiming for a damaged item, please supply a quotation for the repair.

 A loss report from the relevant authority you reported the loss to: e.g. Police Report, Hotel, or Airline

 If applicable, a letter from the carrier outlining any compensation paid to you.

 Your travel tickets and baggage tags.

1. Date of Incident: ____/____/____ 2. Time: ______________ 3. Location & country: ________________________________________ 4. Please describe what occurred (attach a separate piece of paper if you need more space): ___________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ 5. Have you sought or received any compensation? If yes, please provide details of the payer and the amount:

_________________________________________________________________________________________________________________________ 6. Did you report the event to the police? ( ) Yes ( ) No If yes, please attach the police report

7. Please complete the below schedule in full:

Item Purchase Date Place of Purchase Amount Paid Amount Claimed

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Section 3: Travel Delay or Baggage Delay or Flight Misconnection Claim

 Written advice from the airline confirming the duration and reason for delay.

 Please advise if you have received any compensation from the airline including travel, food or accommodation.

 Any communication received from the airline relating to the delay.

 If you are claiming for Luggage delay, please ensure that you supply original receipts or other suitable proof of purchase of necessary, reasonable essential clothing and toiletries.

Original Flight Details Delayed Flight/Luggage Details Date of departure: Date of departure/returned luggage: Time of departure: Time of departure/returned luggage:

Place of departure: Place of departure:

Flight number(s): Flight number(s):

Airline(s): Airline(s):

Other information (if needed):

_________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________

Section 4: Cancellation Claim

 A letter from your travel agent confirming all cancellation costs.

 A letter from your travel agent confirming total amount paid and total amount that has been/will be refunded.

 The terms and conditions for all of your travel arrangements.

 Any and all documentation that supports the reason for your cancellation.

 If your travel was cancelled due to a death, a copy of the death certificate. 1. Date you cancelled/adjusted your trip: ____/____/____

2. Date of the incident that caused the cancellation/adjustment: ____/____/____ 3. Was this due to a medical reason? ( ) Yes ( ) No

If yes, please have the Doctor who recommended cancellation complete the attached medical certificate (last page). 4. (If applicable) Name of person who was ill/injured: _________________________________________________________________ 5. Description of illness/injury: _________________________________________________________________________________________ 6. Has the ill/injured person suffered from the same/similar illness/injury in the past? ( ) Yes ( ) No

7. Date you booked your trip: ____/____/____ 8. Date you cancelled your trip: ____/____/____

9. Further details of why you cancelled/adjusted your trip: _____________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ 10. Please list each item in the table below:

Description Purchase Date Place of Purchase Amount Paid Less

Refunds Amount Claimed

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Section 5: Other Claim (Any Other Reason for Claiming)

 Every document relevant to the cause of the claim, which would be needed to complete the assessment.

 Please provide as much information as possible, including any supplemental letters or receipts etc.

In detail please describe the event that resulted in this claim. If there is not enough room in the space provided, please attach a separate piece of paper.

_________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ Please confirm amounts paid and any key dates: ________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________

CLAIM FORM SUBMISSION

I/We confirm that this claim form has been completed in full and all available, required information is attached. I/We confirm that the information given is true and that no information has been withheld.

I/We acknowledge that this claim will be declined if any part is false, intentionally inaccurate or withheld. I/We acknowledge that if this claim is fraudulent, it will be reported to the relevant authorities.

I/We consent to the collection, use and disclosure of personal information for the purpose of completing this claim. Name (PLEASE PRINT): __________________________________________________________________________________________________ Signature: __________________________________________________________________________ Date: ______________________________

PAYMENT DETAILS

All payments for accepted claims will be deposited directly to your bank account. If your bank details are not provided we will not be able to issue a payment to you.

Bank Name: __________________________________________________________________________________________________

Bank Address: ________________________________________________________________________________________________

Bank SWIFT Code: ____________________________________________________________________________________________

Beneficiary Name: ____________________________________________________________________________________________

Beneficiary Address: __________________________________________________________________________________________

Beneficiary phone number: ___________________________________________________________________________________

Account No: _______________________

__________________________________________________________________________________

Please send the completed claim form and/or any additional documents to support your claim to: 1. Email your claim form and documents to SimasNet-claims@covermore.co.id

OR

2. Mail your claim form and documents to PT. Asuransi Simas Net

Plaza Simas Lt. 7

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MEDICAL CERTIFICATE

Please have this form completed by the patient’s usual Doctor for all claims resulting from accident, illness or death. The cost of completing this certificate is the responsibility of the policy holder.

Name of the patient: ____________________________________________________________________ Date of Birth: ____/____/____ Please complete the certificate in capital letters providing as much information as possible. We thank you in advance for your assistance.

1. Are you the patient’s usual Doctor? __________________________________________________________________________________ 2. If not, do you have access to their medical records? __________________________________________________________________ Please only complete question 3 or 4. The claimant will indicate which question is applicable.

3. Cancellation or adjustment of travel arrangements prior to departure.

(a) Did you recommend that the patient cancel or postpone their travel due to their condition? ________________________ (b) Please provide details about the illness or injury (including final diagnosis): _________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ (c) On what date did you recommend that travel should be cancelled? ____/____/____

(d) On what date did the patient first become aware of their symptoms? ____/____/____

(e) On what date were you first made aware of the condition, or change in the condition? ____/____/____

(f) Has the patient previously been investigated, diagnosed or treated in respect for same/similar/related illness or injury? _________________________________________________________________________________________________________________ (g) If yes, please provide details from the patient’s history (e.g. dates of incidents, advice, treatment,

medication):____________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ (h) Were the travel arrangements booked against your advice, or the advice of another medical professional?

_________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________

OR

4. Medical expenses or additional expenses incurred during travel.

(a) What do you understand to be the illness or injury which resulted in the need to obtain medical treatment or adjust the travel plans of the patient? ________________________________________________________________________________________ (b) Has the patient previously been investigated, diagnosed or treated in respect of the same/similar/related illness or injury? _________________________________________________________________________________________________________________ (c) If yes, please provide details from the patient’s history (e.g. dates of incidents, advice, treatment,

medication):____________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ (d) Prior to departure, was there any indication that medical care may be required? ____________________________________ (e) Was the patient non-compliant with medical advice whilst before or during the journey? ___________________________ _________________________________________________________________________________________________________________________ (f) Did the patient travel against your advice or the advice of another medical professional? ____________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ I certify that the statements contained in this medical certificate are true and correct.

Doctor’s Signature: ____________________________________________________________Date:____/____/____ Doctor’s Stamp: