RS-19-03-TRV02
Section 1: To be completed by claimant/insured
Name of Claimant/Insured
Policy Number
Address (street, city, state, zip)
Date of Birth Policy Purchase DateTrip Departure Date
Gender
Male Female
About the Claimant
About the Patient - Complete only if different from Insured
Name of Patient
Relationship of Patient to Insured
Was patient traveling with insured?
Yes No
Section 2: To be completed by physician
Diagnosis / ICD-9 Code (primary diagnosis)
Diagnosis / ICD-9 Code (secondary diagnosis)
Date patient rst consulted you for this condition
Date symptoms rst appeared
Has the patient ever had this condition before?
Yes No
If yes, when?
Is this condition an exacerbation or a
complication of an existing condition?
Yes No
If yes, what was that condition?
If the patient was referred from another physician,
name and phone number of that physician
If the patient was referred to another physician,
name and phone number of that physician
Dates of medical visits as they relate to the condition causing the trip cancellation/interruption.
Date of consultation
Describe Condition/Treatment
Has the patient been hospitalized for this condition
or related conditions in the past 12 months?
Yes No
If yes, date of admittance and date of discharge?
About the Diagnosis and Treatment
About the Medical Condition as it relates to Travel
Was the Insured/Traveler unable to travel on the policy purchase date listed in Section 1 above?
Yes No
If the patient was Traveler, did you advise patient to cancel or interrupt the trip due to the medical condition?
Yes No
If yes, please explain:
Date you advised patient to cancel trip:
If no, on what date was it reasonable for the
patient/insured to cancel/interrupt their trip?
Claims Department: Red Sky Claims, C/O Arch Insurance Company
Executive Plaza IV, 11350 McCormick Road, Suite 102, Hunt Valley, MD 21031
Phone No: 1-844-800-2486 | Fax: 443-279-2901 | Email: redsky@archinsurance.com
Attending Physician’s Statement
