Fillable Cover-More Claim form

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Cover-More Claim form

On average this form takes 135 minutes to complete

The Cover-More Claim form form is 18 pages long and contains:

  • 5 signatures
  • 58 check-boxes
  • 494 other fields

Country of origin: AUSTRALIA
File type: PDF

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Claim form
How do I make a claim with Cover-More?
The easiest way to submit a claim with Cover-More is to use our Online Claims Tool at
commbank.com.au/cbatravelclaims
You can make your claim with Cover-More in 3 simple steps:
1
Fill out the claim form
Please look at the below table to see which sections of the claim form are needed for your claim and what pages they can be found on.
I am claiming for: I need to fill out: On pages:
A medical cost I incurred overseas Part 1, Part 2, Medical form 2-3, 9-10
Additional transport or accommodation costs I incurred on
my trip
Part 1, Part 3, Medical form is needed if the event was an
illness/injury
2-3, 4, 9-10
The cost of amending/cancelling my trip Part 1, Part 4 2-3, 5-6
- due to illness Medical form 9-10
- and I have a travel agent Travel agent form 11-12
Lost/stolen/damaged luggage or money Part 1, Part 5 2-3, 7
Clothing and toiletries I purchased due to a luggage delay Part 1, Part 6 2-3, 8
Rental vehicle insurance excess Part 1, Part 7 2-3, 8
Something not listed above e.g. Transit Accident Insurance or
Purchase Security
Part 1, Part 8 2-3, 8
If you have more than one reason to claim E.g. lost luggage at the start of your trip and a medical bill at the end), please fill out all relevant parts of
the form.
2
Provide all relevant documentation
• Each section of the claim form has a checklist of the documents we require to support your claim
• If you can’t provide any of the documents we request, please include a letter explaining why
• We accept documents in a foreign language
3
Send us your claim
cbaclaims@covermore.com.au (you can send up to 10 MB of attachments)
Card Insurances, C/o Cover-More, PO Box 2027 North Sydney NSW 2059
(registered or express post recommended)
02 9383 8872 (scanning and emailing your claim is recommended over faxing)
What happens next?
• If you submit your claim via email, you will receive a confirmation email, and then our response to your claim within 10 working days.
• If you submit your claim via post or fax, we will contact you with our response to your claim within 10 working days.
Please do not staple or glue the pages of this claim form or any included documents together before submitting to our office.
© April 2019 Cover-More Insurance Services Pty Ltd Page 1
Part 1: General information - All questions in this section must be answered for all claims
Your policy number
OR
Please provide the following information regarding your eligible Commonwealth Bank credit/debit card.
Name on card
The first six digits on your card
The last four digits on your card
Are you a cardholder for this credit account?
Yes
No, if “No” what is your relationship to the cardholder?
Were you with the cardholder at the time of the event
Yes
No Do you permanently reside with the cardholder?
Yes
No
Title Given name(s) Surname Date of birth
/ /
Occupation Mobile phone (or best other contact) Email address
Postal address Suburb State Postcode
b. Payment
If your claim is approved we will deposit your settlement into your nominated bank account below (we cannot make payments to a credit card).
We prefer to pay successful claims directly into your bank account as it is faster and safer.
Name of bank Branch
Account holder name BSB number Account number
-
(If you do not complete above payment details, we will post you a cheque which may take up to five additional days.)
Please ensure that the bank account details you provide to us are correct. We will not be liable for any loss that you suffer as a result of payment(s)
made to an incorrect bank account because the details you have supplied were incorrect. If you are unsure of your bank account details, please contact
your bank or financial institution for assistance.
c. ABN holders
Are you registered for GST purposes?
Yes - Fill out your ABN and answer all questions under c. ABN Holders
No - Proceed to e. Your declaration
ABN
Have you claimed or are you entitled to claim an Input Tax Credit (ITC) in
respect to the GST paid on the insurance policy under which this claim is
being made?
Yes
No
If Yes, what percentage of the GST did you claim or are you entitled to claim?
(if the GST paid and your ITC entitlement are the same amount, the answer to
this question is 100%)
WARNING: We are committed to investigating claims to avoid passing the costs of dishonest and fraudulent claims on to you. We try to conduct
investigations quickly and with minimal disruption. Fraud will be reported to the police.
Unsure? Contact Cover-More to obtain a copy of the Certificate of
Insurance. For credit/debit card insurances, where you don’t have a
policy number please enter your card information. We cannot use the
full details to identify your full credit card number.
Your credit/debit card information
a. Your information
continued on page 3
d. Your declaration
I/we declare that:
• all statements and particulars stated on this form and all documents submitted are true and correct.
• I/we will cooperate fully with the insurers in the assessment of my claim.
• I/we have not withheld any material information connected with this claim that will inhibit the insurer’s ability to make a fair and reasonable
assessment of my claim.
• I/we acknowledge that my personal information may be disclosed to, and obtained from, certain other parties including the Insurance Reference
Services database, other insurers and government agencies.
• I/we assign to the insurer all rights of recovery/salvage against any person or organisation and will cooperate to secure such rights.
• I/we have read and understood the Privacy Notice on page 13.
• you may send the personal information included on this form and related documents overseas to assess investigate and pay my claim.
I understand that this information may not be subject to the same level of Privacy as is offered by the Australian Privacy Regime and that I will not
be able to seek redress under the Privacy Act 1988 in the overseas jurisdiction.
• where I/we provide information, including sensitive information, about other individuals, that I/we have informed them (or their parent, guardian,
executor or Power of Attorney) of the personal information being provided and the contents of the Privacy Notice and have obtained their consent
to providing the information.
Signature of claimant(s)
Date
/ /
Signature of claimant(s)
© April 2019 Cover-More Insurance Services Pty Ltd Page 2
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signature
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Part 1: General information - All questions in this section must be answered (continued)
e. Claim details
Date of incident Time
/ /
AM/PM
Country
Town
Whereabouts/location
Please provide an explanation of your claim and why you are claiming
(Please include a letter if more space is required).
If the claim was caused by a health condition/dental problem/death
please answer the following questions:
Person whose state of health/dental problems/death caused the claim
Given name(s)
Surname
Relationship of that person to you
Has the illness/injury occurred before?
Yes
No
If Yes, advise
the condition.
Were you/was the person treated as a hospital inpatient overseas?
Yes
No
Date admitted Time admitted
/ /
AM/PM
Date discharged Time discharged
/ /
AM/PM
Did you/the person contact the 24 hour emergency assistance team?
Yes
No
Part 2: Overseas medical and dental
REQUIRED DOCUMENTATION: FOR OVERSEAS MEDICAL AND DENTAL CLAIM
Original itinerary
Medical reports from the treating overseas medical provider which
confirm the diagnosis.
All invoices and receipts.
If the claim is due to a dental condition, we require written
confirmation from the treating dentist that the treatment was not
caused by or related to the deterioration and/or decay of teeth or
associated tissue.
The Medical Authority (page 9) completed by the person whose
state of health caused the claim or Executor of the Estate if
applicable.
The Medical Certificate (pages 9-10) completed by your usual
medical practitioner. Please note: If you are unable to provide
this or don’t have a usual G.P., we may have to request Medicare
records which can delay the processing of your claim.
A copy of your original itemised invoice for your travel
arrangement.
Please list each bill/receipt separately:
Paid?
Name of doctor, dentist, pharmacy, hospital or provider Date of treatment, consultation etc. Amount charged Currency Y/N
E.g. Dr T Smith, New York Medical Centre
1
9
/
1
1
/
1
4
$180.00
/ /
/ /
/ /
USD
© April 2019 Cover-More Insurance Services Pty Ltd Page 3
3. Were your original plans above pre-paid?
Yes
No
Partly paid
4. If your original plans were pre-paid, did you receive a refund?
Yes No If Yes, please advise the amount
5. If your claim is due to travel delay please advise when you were due to depart and when you actually departed.
When were you due to depart? When did you actually depart?
Date Time Date Time
/ /
AM/PM
/ /
AM/PM
Mode of transport Transport provider name
2. If the above event had not occurred, what were your original plans for the same period?
Original expected plan Expected cost Original expected plan Expected cost
1. E.g. Flight AUD$100 5.
2. 6.
3. 7.
4. 8.
Please complete this section if you are claiming for expenses incurred as a result of an unforeseen event.
E.g. Accommodation and transport expenses.
1. Please provide a full description of why the additional expenses were incurred.
Description of cost Amount claimed Description of cost Amount claimed
1. E.g. Flight AUD$200 5.
2. 6.
3. 7.
4. 8.
REQUIRED DOCUMENTATION:
Original itinerary
All invoices and receipts.
If your claim is due to travel delay:
You will need to supply a letter from the transport provider that
confirms the length and reason for the delay as well as any
compensation offered.
If caused by a medical condition:
If the expenses were incurred due to someone’s health, you
will need to supply a medical report from the treating overseas
medical practitioner confirming the nature of the illness or injury
that gave rise to your claim.
The Medical Certificate (pages 9-10) completed by your usual medical
practitioner for claims due to a medical condition, illness or death
(i.e. not an injury).
The Medical Authority (page 9) completed by the patient whose
health has caused the claim or the Executor of the Estate for
claims due to a medical condition, illness or death (i.e. not
an injury).
Part 3: Additional expenses
© April 2019 Cover-More Insurance Services Pty Ltd Page 4
Part 4: Amendment or cancellation costs
Please provide consent by signing below if you would like your travel agent to be able to provide and receive information, including sensitive
information, relating to this claim.
Your travel agent’s name Name of the travel agency
Signature of policyholder(s) Date
/
/
1. Were all of your travel arrangements booked by a travel agent?
Yes - You do not need to fill out the following. Instead, please have your travel agent complete the ‘Agent form’ on pages 11-12.
No - Please fill out the table following for any arrangements that you booked yourself. If any of your travel arrangements were booked by a travel
agent, please have them fill out pages 11-12.
You only need to complete the following for travel arrangements being claimed that were not arranged by a travel agent.
Your policy covers you for amendment or cancellation, whichever is the less (subject to policy limits and the terms and conditions of the Product
Disclosure Statement). Firstly you need to work out how much it would cost you to amend your journey (e.g. to travel at a later date) compared to the
non-refundable amount you won’t be able to get back if you cancel the journey. In most cases it is more cost effective to amend your journey rather
than cancel it. If you have not made any changes to your travel plans yet as a result of a potential claim under this section, please phone us and we
will guide you.
2. On what date did you cancel/amend your journey?
/ /
3. Can you travel on different dates?
Yes
No If No, please explain the reason why you have not amended the journey.
continued on page 6
REQUIRED DOCUMENTATION:
Original itinerary
A copy of your original itemised invoice for your travel
arrangements.
If due to someone’s health (medical condition, injury or death):
The Medical Certificate (pages 9-10) completed by the usual
medical practitioner.
The Medical Authority (page 9) completed by the person whose
state of health caused the claim or the Executor of the Estate.
Additionally, if the claim is due to someone’s death you will need
to provide a full copy of the Death Certificate (not an extract) that
states the cause of death.
*Please note that you can obtain the travel information required
below from your travel agent or supplier directly.
International flights documentation (for any international
flights)
• A copy of the airline’s fare sheet/rules (showing the fare
conditions).
• N.B.: Please check the conditions as many airlines have waivers
E.g. in the case that a passenger or their relative dies, you may be
able to claim a refund from the airline with the submission of a
medical or death certificate. This must be applied for first before
submitting a claim.
Domestic flights documentation (for any domestic flights)
• Confirm if the ticket has been changed to travel at a later date. If
the date hasn’t been changed, there is a 12 month credit allowance
that is available for use through the airline. If the customer
is unable to use the credit, the customer will need to obtain
confirmation that the credit has been cancelled before claiming for
it through their travel insurance policy.
Land arrangements documentation (for any land bookings)
• We require a copy of the providers booking conditions showing
the published cancellation penalties. This is usually shown in the
back of the relevant brochures.
• If the booking conditions do not specify exactly what cancellation
fees apply (E.g. cancellation fees may be up to 100%) then we
require written confirmation from the wholesaler confirming how
much you are to be refunded.
Cruise documentation (for any cruises)
• We require a copy of the providers booking conditions showing
the published cancellation penalties. This is usually shown in the
brochures.
• We also need a breakdown of any tax component (I.e. port taxes)
that should be refundable.
© April 2019 Cover-More Insurance Services Pty Ltd Page 5
Please fill out this
column for any
amended travel
arrangements
Please fill out this column for any cancelled travel arrangements
$
If the trip was cancelled outright prior to departure what would it have cost to amend the trip to different dates
(rather than cancel outright)?
OR
A.
Amount paid
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Fully refundable
by the airline
B. Amount
refunded by supplier
Cancellation costs
Amount claimable
(A minus B)
$0
Amendment costs
$500
Travel arrangement
Flights
(excluding
taxes)
Flight
taxes
Accommodation
Packages
Other
(I.e. car hire,
rail passes,
transfers etc.)
E.g. Flight
$2500 $500
$2000
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
$
Total
$
Total
Part 4: Amendment or cancellation costs (continued)
© April 2019 Cover-More Insurance Services Pty Ltd Page 6
Part 5: Lost/stolen/damaged luggage or money
1. How did the loss/theft/damage occur? (please include a letter if more space required). If the items you are claiming for were with another person
at the time of loss, please provide their full name and contact details, and please describe how they are known to you.
2. Did you contact our emergency assistance team?
Yes
No
3. Were the police or a responsible authority notified?
Yes
No Report reference number
If No, please explain why this policy requirement was not met.
4. If you are claiming for spectacles, dentures or a hearing aid, these items are normally claimable against your health fund.
Do you have a private health fund?
Yes
No Please include evidence of the amount paid by your Private Health Insurer.
5. If a transport provider caused this loss, have you submitted a claim with them?
Yes
No
If No, there is a liability imposed on airlines by the 1999 Montreal Convention for costs associated with lost or delayed luggage so you should claim
from them before submitting your claim to us. For other transport providers you also need to submit a claim directly to them in the first instance.
Travel insurance protects you against the amount the responsible transport provider is unable to compensate you for, subject to your policy
conditions and limits.
If Yes, please give details and the claim reference number.
6. Have you received compensation from the airline or transport provider?
Yes
No
If Yes, what amount did you receive in compensation? Please make sure you include written confirmation of this amount.
Please list all items you are claiming in the table below.
WARNING: Claiming for items that you never owned, claiming for items that were not lost or stolen, inflating the amount of your claim or
providing false or misleading information about how the loss occurred is fraud. As fraudulent claims increase travel insurance premiums for all
customers, Cover-More has a dedicated team of fraud specialists that investigates all claims.
Full description of each item
Brand, model,
number etc
Month & year
of purchase
Place of purchase
Proof of
ownership
attached?
Have you
replaced
this item?
Original purchase
price and currency
or repair quote
E.g. T-shirt 01/15 AUD$25.00
REQUIRED DOCUMENTATION:
Original itinerary
A copy of your original itemised invoice for your travel arrangements
For lost or stolen items:
Loss/theft report. E.g. police report, hotel report. The report needs to come from a responsible authority to confirm that your loss took place.
For items lost or stolen while in the custody of a transport provider, we require a letter from the transport provider confirming that the loss has
been reported to them by you and advising the amount of compensation they are paying to you for your loss.
For all items, we will require proof of ownership.
As proof we will consider:
Item
Receipt or duplicate
receipt from the
place of purchase
Mobile service provider contract
showing terms of ownership
Other proof (this could be instruction manuals,
warranty cards, credit card/bank card statements,
photographs or packaging)
Electrical items (including camera, laptops, MP3
players, tablet computers, etc.)
✓
Mobile phones (including smart phones)
✓ ✓
All other items
✓ ✓
For mobile phones we also require a mobile network service provider letter which confirms the handset is barred and the mobile device disabled.
For all items you have replaced already, please send in copies of the receipts for the replacement items.
For damaged Items:
Obtain from a repairer (of your choice) a quote stating the nature of the damage and the repair cost or a letter stating that the item is damaged
beyond economical repair. We may request the damaged item to be sent to us so please keep it.
If the item is damaged beyond economical repair, please also send in proof of purchase (please see table above for the kinds of proof we
will consider).
OR
OR
© April 2019 Cover-More Insurance Services Pty Ltd Page 7
Date of incident Time Country Location
/ /
AM/PM
How did the accident/damage/theft occur?
Excess you were liable to pay Repair costs Amount you are claiming
Did the damage occur whilst driving on an unsealed surface?
Yes
No
Was there another party at fault?
Yes
No
If Yes, please provide the name and address of the at fault party as well as their insurance details if known.
Did the police attend the scene?
Yes
No Have you received compensation from any person or party involved?
Yes
No
If Yes, what amount did you receive in compensation? Registration number of the at fault party vehicle
Note: If the cost of repairs was less than the excess charged, please contact the rental car company to obtain a refund of the difference.
This section is for any other expenses not mentioned above.
Nature of expense Amount claimed Nature of expense Amount claimed
1. E.g. Toothbrush AUD$5.00
4.
2. 5.
3. 6.
Please forward relevant supporting documentation to assist us in processing your claim. For more information, contact Customer Service on 1300 467 951.
Part 8: Other expenses claimed
Have you received compensation from the airline? Yes No If Yes, what was the compensation amount?
Please include confirmation
If No, for items lost or stolen while in the custody of a transport provider, we require a letter from the transport provider advising the amount of
compensation they are paying. Travel insurance protects you against the amount the transport provider is unable to compensate you for, subject to
your policy conditions and limits. You need to claim compensation from the transport provider in the first instance before submitting your claim to us.
When did your flight arrive? When did you receive your luggage back?
Date Time Date Time
/ /
AM/PM
/ /
AM/PM
Description of items purchased Price and currency Description of items purchased Price and currency
1. E.g. Jacket USD$60.00 4.
2. 5.
3. 6.
For the traveller(s) affected, how many bags did you check in?
How many of these bags were delayed?
Part 6: Delayed luggage
REQUIRED DOCUMENTATION:
Original itinerary
A copy of your original itemised invoice for your travel arrangements
Loss report from the transport provider with confirmation that all
of your luggage was delayed, the length of time your total luggage
was delayed and details of compensation paid by them.
Itemised receipts for essential, emergency purchases of clothing
& toiletries (made whilst your luggage was delayed).
REQUIRED DOCUMENTATION:
Original itinerary
The Rental Agreement/contract showing the excess you were
liable to pay in the event of damage or theft.
A copy of the itemised repair invoice showing the cost of
repairs to the vehicle.
A copy of the documents showing the amount debited by the rental car
company for the damages/excess.
The report made to the police or other relevant authority.
If another party was at fault, written confirmation from them of the
compensation payable by them/their insurer.
Part 7: Rental vehicle insurance excess
© April 2019 Cover-More Insurance Services Pty Ltd Page 8
To be completed by the person whose state of health caused the claim (or their Parent/Guardian, Executor of the Estate or Power of Attorney if
applicable). Details of the patient’s usual doctor (of at least 12 months prior to the policy issue date).
I, __________________________________________ voluntarily authorise and direct any hospital, doctor, dentist or other third party or person who has
medically attended or examined __________________________________________ to provide Cover-More Insurance Services Pty Ltd (Cover-More) and
it’s employees, representatives and related bodies corporate, any and all information and records with respects to any mental or physical illness or
injury, medical history, consultation, prescriptions or treatment that were rendered to them.
I understand and agree that this authorisation will allow Cover-More to use the information obtained to investigate and adjudicate the claim.
A photocopy of this authorisation shall be considered to be as effective and valid as the original.
Signature of patient/Executor/Power of Attorney Patient’s name Date of birth
/ /
Relationship to patient (if applicable) Doctor’s or dentist’s phone number Doctor’s or dentist’s fax number
Doctor’s or dentist’s email or postal address (include postcode)
Name of usual doctor or dentist
To be obtained at the claimant’s own expense from the patient’s usual medical/dental practitioner (whom they have been attending for at least 12
months prior to the issue date of the policy). Required for all claims arising from a person’s health/medical condition, death or dental condition. If
you do not have a usual medical/dental practitioner, please contact us.
IMPORTANT: The medical/dental practitioner is respectfully requested to give as much detail as possible when answering these questions in order
to assist our client with their claim and avoid the necessity of additional questions. PLEASE USE BLOCK LETTERS. You may reply in letter format
however answers to each of the questions below that are relevant to your patient or the claim being made by the claimant will need to be included.
1. Name of patient 2. Date of birth
/ /
3. Are you the patient’s usual G.P. or dentist?
Yes
No
a. If Yes, for how long? b. If No, do you have access to their medical records?
Yes
No
From what date?
/ /
4. Please give a precise diagnosis of the illness or injury or cause of death that has given rise to the claim. If an injury, how was it sustained?
5. On what date did the patient first consult You in relation to this condition or symptoms of this condition?
/ /
6. Have you or anyone else known to you previously treated or advised this patient in respect of the same/similar/related illness or injury as
described in the answer to question four?
Yes
No
7. Prior to the policy issue date, was the patient receiving any regular advice, treatment or medication or being investigated for this condition
or any similar/related condition?
Yes No If Yes, please give details and please provide details and include copies of all letters from
referred specialists, the patient’s full medical history, current medications and all hospital visits for the past two years.
8. Did you advise the patient to take medication for this condition before or whilst on the journey?
Yes
No
9. Was there any indication prior to travel that medical care might be required on the journey?
Yes
No
Medical Certificate (To be completed by the patient’s usual doctor/dentist)
Medical Authority (To be completed by the person who was ill/injured)
Medical form
(Page 1 of 2)
Submit the claim to Cover-More by: Post Card Insurances, C/o Cover-More, PO Box 2027, North Sydney NSW 2059 Australia
Fax (02) 9383 8872 Email cbaclaims@covermore.com.au
Signed date
/ /
continued overleaf
© April 2019 Cover-More Insurance Services Pty Ltd Page 9
click to sign
signature
click to edit
10. Please provide details of the patient’s health at the time when the insurance was issued and the likelihood of the patient’s health leading to
hospitalisation or death after this time.
11. Please provide the following dates, where applicable.
a. Date of onset of illness/injury/death and/or b. Date tests prescribed c. Date tests carried out
date of deterioration/exacerbation
/ / / / / /
d. Date results advised to the patient e. Date referred to specialist/surgeon f. Date of death
/ / / / / /
g. Name and address of specialist/surgeon
12. Date the patient was advised that they would not be able to travel. / /
13. If due to pregnancy:
a. On what date was the pregnancy confirmed? b. How many weeks pregnant was the person on this date?
/ /
c. Was the conception medically assisted?
Yes No
d. Have there been previous complications with this or any other pregnancy?
Yes No
14. Was the patient on a waiting list for hospital?
Yes
No If Yes, please give details.
15. Was the patient hospitalised?
Yes
No
If Yes, please provide admission date
/ /
I certify that I have examined the patient named above and/or have referred to their medical records and confirm that the information given in this
Medical Certificate is a true and correct statement.
Doctor’s or dentist’s signature Name Date
/ /
Email address, fax number or postal address
Qualification Telephone
REQUIRED DOCUMENTATION:
Please note: Failure to fully complete the form above or to send the documentation below, could result in a delay to processing our
customer’s claim. What you need to include:
A copy of the Patient Health Summary sheet
A copy of the initial referral letter to the Specialist (if applicable)
A copy of all clinical discharge summaries for any hospital admissions within the last two years
Medical form
(Page 2 of 2)
© April 2019 Cover-More Insurance Services Pty Ltd Page 10
Customer name(s)
Agent form: Amendment or cancellation costs
Please submit this form and all supporting documents directly to Cover-More and provide a copy to your customer.
The policy covers the commission you had earned on the booking (subject to the policy limits). In order to calculate this we need to know how much
the customer has paid to you and the net amounts paid to the booking provider I.e. the wholesaler, airline or cruise company. This information is not
shared with customers. Enquiries will be directed back to the consultant.
N.B.: We do not cover any additional agency cancellation fees you charge your customer or additional monies held by your agency that are due to be
refunded to the customer.
Please also make sure you have provided your customer with the option of amending their travel plans rather than cancelling. The policy covers the
lesser of amendment or cancellation costs.
Agent form
Amendment/cancellation of bookings made with a travel agent
Submit the claim to Cover-More by: Post Card Insurances, C/o Cover-More, PO Box 2027, North Sydney NSW 2059 Australia
Fax (02) 9383 8872 Email cbaclaims@covermore.com.au
$
Total
$
Total
$
If the trip was cancelled outright prior to departure what would it have cost to amend the trip to different dates
(rather than cancel outright)?
OR
A.
Amount paid
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Fully refundable
by the airline
B. Amount
refunded by supplier
Cancellation costs
Amount claimable
(A minus B)
$0
Amendment costs
$500
Travel arrangement
Flights
(excluding
taxes)
Flight
taxes
Accommodation
Packages
Other
(I.e. car hire,
rail passes,
transfers etc.)
E.g. Flight
$2500 $500
$2000
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
Customer name(s)
continued overleaf
© April 2019 Cover-More Insurance Services Pty Ltd Page 11
REQUIRED DOCUMENTATION:
Please note: Failure to send the documentation below or failure to fully complete the form above, could result in a delay to processing your
customer’s claim. What you need to include:
A copy of your customer’s itinerary
A copy of the itemised invoice
International flight documentation
(for any international flights)
• A copy of the airline fare sheet/rules (showing the fare
conditions).
• NB: Please check the conditions as many airlines have waivers
e.g. in the case that a passenger or their relative dies, the
customer may be able to claim a refund from the airline with the
submission of a medical or death certificate. This must be applied
for first before submitting a claim.
Domestic flight documentation (for any domestic flights)
• Virgin Australia: Confirm if the ticket has been changed to travel
at a later date. If the date hasn’t been changed, there is a 12
month credit allowance that is available for use through the
airline. If the customer is unable to use the credit, the customer
will need to obtain confirmation that the credit has been
cancelled before claiming for it through their travel insurance
policy.
• Other airlines: Confirm if the ticket has been changed to travel
at a later date. If any amounts are being held in credit with the
airline, the customer will need to obtain confirmation that the
credit has been cancelled before claiming for it through their
travel insurance policy.
Land arrangement documentation (for any land bookings)
• We require a copy of the providers booking conditions showing
the published cancellation penalties. This is usually shown in the
back of the relevant brochures.
• If the booking conditions do not specify exactly what cancellation
fees apply (e.g. cancellation fees may be up to 100%) then we
require written confirmation from the wholesaler confirming how
much the customer is to be refunded.
Cruise documentation (for any cruises)
• We require a copy of the providers booking conditions showing
the published cancellation penalties. This is usually shown in the
brochures.
• We also need a breakdown of any tax component (i.e. port taxes)
that should be refundable.
Remember to make a copy of all documents submitted for your
customer in case they become lost in the mail.
Did you know that many airlines offer a cancellation waiver
due to the death of a passenger or close family member?
Please ensure you check the airline terms and conditions as many
airlines offer this waiver even on non-refundable tickets, with the
submission of the death or medical certificate.
Here is an example of an airlines waiver in regards to death:
“waiver permitted for death of a passenger/an accompanying
passenger/immediate relative as defined in general rules/legal
guardian or ward as validated by a death or medical certificate”.
Check the terms and conditions relevant to the customer’s other
bookings to see if they are entitled to this refund as these need to be
applied for prior to submitting a claim form to Cover-More.
AUSCM_C001_CBAClaimForm_APRIL 2019
I certify that the information stated on this form is true and correct and I have supplied the required documentation.
Consultant’s name Consultant’s signature
Travel agency name and address Date
/ /
Phone Fax Email
( ) ( )
Before submitting your customer’s claim, ensure you have included the required documentation, as listed below.
© April 2019 Cover-More Insurance Services Pty Ltd Page 12
Privacy notice
Cover-More and your personal information
Why we collect your personal information
We collect your personal information (including sensitive information)
so we can:
• identify you and conduct necessary checks
• determine what services or products we can provide to you or others
• issue, manage and administer services and products provided to you
or others including claims investigation, handling and payment
• improve our services and products e.g training and development of
our representatives, product and service research, data analysis and
business strategy development
• make special offers of other services and products that might be of
interest to you.
What happens if you don’t give us your personal information?
If you choose not to provide us with the information we have requested,
we may not be able to provide you with our services or products or
properly manage and administer services and products provided to you
or others.
How we collect your personal information
Through websites from data you, or your travel consultant, input directly
or through cookies and other web analytic tools, via email, by telephone
or in writing.
We collect personal information directly from you unless:
• you have consented to collection from someone else
• it is unreasonable or impracticable for us to do so or
• the law permits us to.
We may also collect additional personal information from other third
parties who help us provide you with our services and products or help
us administer the products.
If you provide us with personal information about another person you
must only do so with their consent and agree to make them aware of
this privacy notice.
Who we disclose your personal information to
We share your personal information with third parties for the purposes
noted above.
The third parties include:
• insurers
• medical providers, travel providers and your travel consultant
• our lawyers and other professional advisers
• our related companies and other representatives or contractors who
we have hired to provide services or to monitor the services provided
by us or our agents, our products or operations
• other parties we may be able to claim or recover against or other
parties where permitted or required by law.
Additional third parties are detailed in our Privacy Policy available on
our website www.covermore.com.au.
We may also need to disclose information to recipients located
overseas. Who they are may change from time to time. You can contact
us for details or refer to our Privacy Policy available at our website
www.covermore.com.au. In some cases we may not be able to take
reasonable steps to ensure they do not breach the Privacy Act and they
may not be subject to the same level of protection or obligations that
are offered by the Act in Australia. By proceeding to acquire our services
and products you agree that you cannot seek redress under the Act or
against us, to the extent permitted by law, and may not be able to seek
redress overseas.
By proceeding with your application, you and any other traveller
included on the policy consent to this use and these disclosures unless
you tell us otherwise, by contacting us.
More information, access, correction or complaint
For more information about how we collect, use or disclose personal
information, how to access or seek correction to your information
or how to complain in relation to a breach of the Australian Privacy
Principles and how such a complaint will be handled, please refer to our
Privacy Policy. It is available on our website www.covermore.com.au or
by contacting us.
Your choices
If you wish to withdraw your consent including for things such as
receiving information on products and offers by us or persons we have
an association with, or your travel consultant receiving information
about your policy and coverage, please contact us.
Contact us
Privacy Officer
Cover-More Insurance Services Pty Ltd, ABN 95 003 114 145
Private Bag 913, North Sydney, NSW 2059
email privacy.officer@covermore.com.au
AUSCM_C001_CBAClaimForm_APRIL2019
© April 2019 Cover-More Insurance Services Pty Ltd Page 13
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