Fillable Claim Filing Instructions

Fill Online, Printable, Fillable, Blank Claim Filing Instructions Form

Use Fill to complete blank online OTHERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Claim Filing Instructions

On average this form takes 23 minutes to complete

The Claim Filing Instructions form is 4 pages long and contains:

  • 0 signatures
  • 20 check-boxes
  • 81 other fields

Country of origin: OTHERS
File type: PDF

BROWSE OTHERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Page 1 of 4
V.08.23.2018 CANCEL/DELAY/INTERRUPT
Trip Cancellation
You were unable to depart on your covered trip.
1. Complete all applicable information starting on page 2.
2. If cancellation was the result of an illness/injury, please have the patient’s physician complete the “Physician’s
Statement” on the attached form.
3. Please submit proof of payment for claimed expenses. Acceptable forms of proof of payment include a credit card
statement and/or a copy of the front and back of the negotiated check.
4. Submit copies of the invoice/reservation for hotel, cruise, and tour bookings.
5. Submit your airline e-ticket if you have one.
6. Submit the travel supplier cancellation notice. This notice should contain the reservation/itinerary/booking
information, date of cancellation, and the penalties.
Trip Interruption
You started on your trip and then had to return home due to an unforeseen event.
1. Complete all applicable information starting on page 2.
2. If the interruption was the result of an illness/injury, please have the patient’s physician complete the “Physician’s
Statement” on the attached claim form – medical records from the date of service are applicable in lieu of a completed
“Physician’s Statement.”
3. Please submit proof of payment for claimed expenses. Acceptable forms of proof of payment include a credit card
statement and/or a copy of the front and back of the negotiated check.
4. Submit copies of all original invoice/reservations for hotel, cruise, and tour bookings.
5. Submit your airline e-ticket (please include original and new ight itineraries).
Single Supplement
Booked a trip with a companion who canceled, resulting in additional charges for you.
1. Complete all applicable information starting on page 2.
2. Please submit all revised booking conrmations showing the revised total cost.
Claim Filing Instructions
Read the instructions for the type of claim you need to le, you may have more than one.
Page 2 of 4
V.08.23.2018 CANCEL/DELAY/INTERRUPT
Primary Insured’s Information
2 Name of Primary Insured 3 Date of birth MM/DD/YYYY
4 Account Number 5 Preferred phone number
6 Email address 7 Fax number
8 Mailing address (if dierent than home) 9 City 10 State 11 Zip code
12 Home address 13 City 14 State 15 Zip code
16 Preferred method of contact:
Mail Email Phone
Travel Supplier / Provider Information
17 Company name 18 Phone number
19 Company mailing address 20 City 21 State 22 Zip code
23 Scheduled date of departure MM/DD/YYYY 24 Scheduled date of return MM/DD/YYYY
25 Actual date of return MM/DD/YYYY (trip interruption/trip delay)
Claimed Expenses
Category Amount Required Supporting Documents
26 Airfare $ E-ticket receipt or original paper airline tickets
27 Lodging $ Documents conrming your reservation/payment/partial payment
28 Tour(s) $ Copy of the invoice
29 Cruise ship $ Booking conrmation
30 Other $ Meals, taxi, any additional expenses
31 Total expenses $
32 Refunds $ Examples: account credits, cash refunds, trip or meal voucher, etc.
33 Total claimed $
34 If You Are Claiming Airline Tickets, Please Complete The Below Section
Your airline tickets may have value up to one year from the original scheduled departure date. Please indicate below whether you will be exchanging your
tickets for another trip. Please note: Your signature on this agreement is not a guarantee of payment. Claim determinations are subject to the terms and
conditions of the plan document.
I (We) will not be using our airline ticket(s). Please enclose a copy of all electronic ticket conrmation(s).
I (We) will be exchanging our airline ticket(s) for future travel. Please enclose a copy of all electronic ticket conrmation(s) along with documentation for
the cost you incurred for the exchange.
1
Reason for Claim
Trip Cancellation Trip Interruption Trip Delay
EF PROGRAM NAME:
EF Educational Tours Go Ahead Tours Ultimate Break College Study Tours Gap Year Explore America
You may check more than one.
Page 3 of 4
V.08.23.2018 CANCEL/DELAY/INTERRUPT
Traveling Companions
35 Companion name 36 Relationship
37 Companion name 38 Relationship
39 Companion name 40 Relationship
41 Companion name 42 Relationship
43 Reason for Cancellation / Delay / Interruption
If Cancellation / Delay / Interruption Due To Medical Reasons
44 Name of person having sickness or injury 45 Date of birth MM/DD/YYYY
46 Relationship to Primary Insured
47a Has the person named in question 44 received medical attention for the
mentioned symptoms or illness? Yes No
47b If YES, please indicate the date you were last treated MM/DD/YYYY
48 Period of Hospitalization (if applicable) MM/DD/YYYY
From: To:
Authorization For Release Of Medical Information – To Be Completed By Patient
In order to process a claim for benets, I authorize any physician, hospital, or other Medical Provider to release to the Seven Corners Insurance Claims
Administrator, or its representative, any information regarding my medical history, symptoms, treatment, examination results or diagnosis. A photocopy of
this authorization shall be considered as eective and valid as the original. This authorization shall be considered valid for the duration of the claim, but not to
exceed two and one-half years from the date signed. I understand I have a right to receive a copy of this authorization.
49 Date MM/DD/YYYY 50 Signature (Signature of Person Suering Illness or Injury or legally authorized representative)
Physician’s Statement – To Be Completed By Physician Only
51 Name of doctor 52 Oce phone number 53 Oce fax number
54 Oce mailing address 55 City 56 State 57 Zip code
58 Name of patient 59 Date of birth MM/DD/YYYY
60 Diagnosis that resulted in cancellation/interruption of trip
61 Date symptoms rst appeared or accident occurred MM/DD/YYYY 62 Date of rst treatment for listed diagnosis MM/DD/YYYY
63 Was patient treated by anyone else? Yes No 63a If YES, by whom? 63b If YES, when? MM/DD/YYYY
64 Was patient prohibited to travel due to this illness/injury? Yes No
65 Date completed MM/DD/YYYY 66 Physician’s signature
Page 4 of 4
V.08.23.2018 CANCEL/DELAY/INTERRUPT
Documentation Requirements
67 Depending upon the circumstance involved in the loss, one or more of the following items may be required to complete the processing of your claim.
Please place a check by those items you have attached. We recommend you keep copies of any items submitted with this claim.
Airline Ticket Stub/Receipt
Copies of canceled checks or credit card statements with an invoice from your Travel Provider showing the date of your deposit. If you wish to
waive the pre-existing condition exclusion on your claim, you must submit proof that you bought this insurance plan within 20 days of your rst
payment for air/land/sea arranements.
Police Report
Statement from Hotel/Motel, Airline Carrier or Airport Facility that concerns your Cancellation/Delay. Note: Any cancellation or delay of ight
must be documented by the airline.
Car Rental Agreement
Copies of reimbursement statements issued by an airline carrier, airport facility, car rental agency, travel agent, hotel/motel or other similar
establishment or any other insurance company providing reimbursement to you for the loss.
Original purchase receipts for additional expenses
Report from common carrier conrming delay
Other (please describe)
Other Insurance / Authorization
68a Do you have any other travel or out-of-country insurance through an
employer, spouse’s employer, retirement plan or credit card? Yes No
68b If YES, please indicate name of insurance company
69 Plan number 70 Credit card issuing bank
I AUTHORIZE any insurance company, physician, hospital, and other health care providers, any travel organization or agency, airline carrier, rental agency, hotel,
motel, or similar entity providing lodging on a rental/lease basis or any other person who may have knowledge regarding this claim, to release any information
requested regarding this claim and the loss reported.
I UNDERSTAND the information obtained by use of the authorization, will be used by Seven Corners to determine eligibility for benets under this plan. Any
information obtained will not be released by Seven Corners to any person or organization EXCEPT to reinsuring companies, or other persons or organizations
performing business or legal services in connection with my claim, or as may be otherwise lawfully required or as I further authorize.
I KNOW that I may request to receive a copy of the Authorization. I AGREE that a photographic copy of this authorization is as valid as the original. I AGREE that this
Authorization shall be valid for two and one half years from the date shown below. I UNDERSTAND that it is illegal to knowingly le a false or fraudulent claim or to
knowingly help someone else le one.
71 Signature 72 Date MM/DD/YYYY
Send this form and any accompanying documents to Seven Corners using any of the following methods:
MAIL
Seven Corners, Inc.
Attn: Claims
303 Congressional Boulevard
Carmel, IN 46032 USA
(Allow mail 7-10 days for delivery.)
FAX
(+01) 317-575-2256
EMAIL
tourclaims@sevencorners.com
Call for help: Local 1.317.582.2658 or Toll-free 1.866.887.7148
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Claim Filing Instructions

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 28 January 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document