Fillable Trip Cancellation / Trip Interruption Claim Form (Trip Preserver online claims)

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Trip Cancellation / Trip Interruption Claim Form (Trip Preserver online claims)

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Trip Cancellation / Trip Interruption
Claim Form
To be completed by the Insured / Guest
Name of Insured / Guest Reservation #
Address Work Phone # Home Phone #
E-mail Address Date of Birth
Date of Initial Trip Deposit Date Incident Occurred Date Cancelled / Interrupted with Property Management Company
Scheduled Departure Date Scheduled Return Date Do you plan to use your airline voucher within one year of original ticket cancellation?
Do you have any other travel insurance? If so, please provide the name and address of the company
Name of leaseholder on the rental property and the names of all guests occupying the property
Complete the following and attach the required documentation (see page 2). Please print clearly. Please briey explain your claim:
To be completed by Insured / Guest if claim is due to sickness or injury
Name of patient DOB (mm/dd/yy) Relationship to Insured / Guest
Was the patient scheduled to go on a trip? (trip activities, cruise, ight, etc.) Destination Departure Date
Date symptoms rst appeared (mm/dd/yy) Date rst seen by physician (mm/dd/yy) Did accident resulting in injury involve a motor vehicle?
If yes, please list the names of all involved parties, insurance carriers, and policy numbers.
Was a police report led? If yes, please identify the Police Department where it was led.
Was the patient treated for this condition prior to insurance purchase? If yes, when?
If trip was cancelled due to death, please provide a copy of death certicate and relationship to Insured / Guest.
Name & address of family physician who rst treated the condition Physician’s Phone # Physician’s Fax #
Name & address of primary care physician where patient resides Physician’s Phone # Physician’s Fax #
Name & address of other physician(s) who treated the condition and specialty Physician’s Phone # Physician’s Fax #
Name of Hospital (if hospitalized) Date(s) Admitted & Discharged Hospital Phone # Hospital Fax #
Indicate other Health Insurance coverage, including name, address, and policy number:
Please advise names of any prescription medications presently taken.
Arch-2014
Yes No
Yes No
Yes No
Yes No
Claims Department:
Red Sky Claims, C/O Arch Insurance Company
Executive Plaza IV, 11350 McCormick Road, Suite 102, Hunt Valley, MD 21031 United States
Toll Free Phone: (844) 800-2486 | Fax: (443) 279-2901 | E-mail: redsky@archinsurance.com
Any person who knowingly presents a false or fraudulent claim for payment of loss or benet or
knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to nes and connement in prison.
Trip Cancellation / Trip Interruption
Claim Form
Claims Department:
Red Sky Claims, C/O Arch Insurance Company
Executive Plaza IV, 11350 McCormick Road, Suite 102, Hunt Valley, MD 21031
Toll Free Phone: (844) 800-2486 | Fax: (443) 279-2901 | E-mail: redsky@archinsurance.com Any
person who knowingly presents a false or fraudulent claim for payment of loss or benefit or
knowingly presents false information in an application for insurance is guilty of a crime and may
be subject to nes and connement in prison.
Required Documents for Trip Cancellation
All of the requested information below is necessary for the processing of the Insured / Guest’s claim.
Any omitted items will delay processing.
3 Verication and documentation of the reason for your trip was interrupted, cancelled or delayed. If interruption was due to
a medical reason, please submit proof of medical treatment at the point of interruption.
3 The Physician’s Statement completed in full by the physician rendering treatment if due to illness or injury.
3 Include any and all receipts and proof of payment, such as cancelled
checks and credit card statements related to your trip costs. Include proof
of insurance payment. Required documents include, but are not limited
to the following:
• Property management company invoice
• Proof of insurance payment
• Total transportation cost (airline, train, or bus tickets)
• Unused airline ticket(s) or original receipt
• Statement from airline providing their cancellation penalties
• Receipt / airline ticket showing the upgrading expense
• Refunds and vouchers received showing refunds
3 If death is the reason for the claim, please provide a copy of death
certicate.
3 If claimant is other than leaseholder, please provide a signed written statement from leaseholder listing all guests
occupying the rental property.
Authorization to Disclose Information
Trip Preserver Product is Underwritten by Arch Insurance Company.
To any medical care provider, medical care facility, insurer, government-sponsored health plan, or employer: I authorize the release
of any medical information about me to Arch Insurance Company, or its authorized representative. This applies to all information
about the diagnosis, treatment, or prognosis of any illness or injury I now have or have had in the past. To any insurance company,
any travel organization or agency, airline carrier, cruise line, your operator, 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: I authorize the release any
information required regarding this claim and the loss reported.
The company will use this information to determine if any claim is eligible. Any information obtained will not be released by the
Company except to my primary health insurance carrier (if any) or persons or organizations performing investigation or legal
services for the Company in connection with my claim. A copy of this authorization shall be considered as eect and valid as the
original and shall remain in eect for one year from the date of authorization. I certify that the information given by me in support
of my claim is true and correct. I understand that any person who knowingly and with intent to defraud or deceive any insurance
company les a claim containing any materially false, incomplete or misleading information may be subject to prosecution or
insurance fraud.
Patient’s or Authorized Representative’s Signature Date
If Authorized Representative, Relationship to Patient
or Legal Designation
Arch-2014
Category Amount
Airfare $ ___________
Rental Cost + $ ___________
Total Expenses $ ___________
Less Refunds - $ ___________
Total Claim
Amounts
$ ___________
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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-traveler’s 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: 1-866-889-7409 | Fax: 443-279-2901 | Email: redsky@archinsurance.com
Attending Physician’s Statement
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Trip Cancellation Trip Interruption Claim Form (Trip Preserver online claims)

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Completed 12 September 2021

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