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
RS-19-03-TRV02
Section 2, continued: To be completed by physician
About the Medical Condition as it relates to Travel, continued
If the patient was non-traveler, did you advise the Traveler to cancel or interrupt the trip due to the non-travelers medical
condition?
Yes No
If yes, please explain:
Date you advised Traveler to cancel trip:
If no, on what date was it reasonable for the
patient/insured to cancel/interrupt their trip?
If related to pregnancy, expected delivery date
If the condition was related to pregnancy, when was
the pregnancy rst diagnosed?
Was the patient hospitalized while traveling?
Yes No
Was this an emergency room admission?
Yes No
Name & Location of Hospital
Date Discharged
Date Admitted
Physician Information and Signature
Specialty
License Number
Physician’s Name
Fax NumberPhone Number
Physician’s Signature
Please note: All of the above requested information is necessary for the processing of the Claimant/
Insured’s claim. Any omitted items will delay processing.
Please attach copies of the patient’s ofce records for the 6 months prior to the trip departure date.
Any person who knowingly and with intent to injure, defraud or deceive any insurance company, les
a statement of claim containing any false, incomplete, or misleading information may be guilty of a
criminal act punishable by law.
I have read the foregoing, and the above answers are true and complete according to the best of my
knowledge and belief.
Date
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
click to sign
signature
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