Fillable Trip Claim Form Step 1 - Choose The

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Trip Claim Form Step 1 - Choose The

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TRIP CLAIM FORM - TIS - 06/2020
Trip Claim Form
Step 1 - Choose The Type Of Claim
Trip Cancellation I am unable to leave on my trip due to an unforeseen event and want to request reimbursement for
non-refundable trip payments and deposits.
I had an unforeseen delay that caused me to have additional out-of-pocket expenses such as unplanned hotel
Trip Delay
accommodations, meals, and local transportation.
I had an unforeseen interruption that caused me to have unused, non-refundable portions of my trip and/or
Trip Interruption
caused me to purchase new or additional airline, bus, or train tickets.
Step 2 - Provide Documentation (provide all)
Provide the following required documentation:
Provide copies or photos of your itinerary and paid invoice.
Provide copies or photos of any documentation that supports
the reason for your claim.
Provide copies or photos of receipts or credit card
statements for out-of-pocket expenses.
Step 3 - Submit All Pages Of This Claim Form
Completed claim form and documentation can be submitted
by either:
Scan/Upload: www.travelexinsurance.com
Email to: travelex.claims@bhspecialty.com
Mail to:
Berkshire Hathaway Specialty Insurance Company
P.O. Box 2986, Clinton, IA 52733-2986
If you have questions about your claim, our customer service team is available by
phone at 855-205-6054, Monday - Friday 7 a.m. - 7 p.m. CST or by email at travelex.claims@bhspecialty.com.
About Me
Name of the person completing form Conrmation/Policy number
(First, Last)
Check if this is a change of address.
City State Postal codeMailing address
Mobile phone Other phone Email address
Full names of all persons claiming Relationship to person completing form
Name of agency/company you purchased your travel insurance from
Date initial deposit paid for trip
(mm/dd/yy)
Claims administered and adjusted by Berkshire Hathaway Specialty Insurance Company for Travelex Insurance
Services, Inc. Insurance is underwritten by Berkshire Hathaway Specialty Insurance Company for all policies.
1
Fax to: 715-303-6328
TRIP CLAIM FORM - TIS - 06/2020
Note – Benets under any coverage will not be paid for expenses
reimbursed or services provided by any other source. Benets
Trip Claim Form
cannot be duplicated under this protection plan and claims will be
adjusted in accordance with the terms of the policy.
About What Happened
Please provide a detailed description
Date of loss Total amount requested for reimbursement
(mm/dd/yy) (USD)
Breakdown Of The Amount Requested For Reimbursement
Description of expense
Amount requested
for reimbursement
(USD)
(USD)
(USD)
(USD)
If you have more expenses, please provide a breakdown on an additional sheet using above format.
Airline Refunds Or Credits Refunds Or Credits Other Than Airline
Your airline tickets may have value for up to one year from the Will/have you applied for a refund or credit
YES
original scheduled travel date. from the travel supplier?
NO
Will you be exchanging your airline ticket(s)
for future travel?
YES
NO
If YES, have you received or do you expect to
receive this refund/credit?
YES
NO
If YES, indicate the amount of refund/credit
amount:
(USD)
If The Claim Has Been Submitted To Another Insurance Company For T
hese Expenses, Please Provide:
Name of insurance company Claim number
I Declare That The Above Information Is True, Complete And Correct.
I authorize any other insurance company, under which I have coverage to disclose information as may be necessary with respect of my claim
with Berkshire Hathaway Specialty Insurance Company directly. I also authorize Berkshire Hathaway Specialty Insurance Company to disclose
to any other insurance company, under which I have coverage, any and all information as may be necessary with respect to my claim.
Signature or typed name of the person completing form Date
(mm/dd/yy)
Person completing this form understands checking this agreement box and typing your name in the signature box above constitutes an electronic
signature and consent to le this claim electronically. Electronic signatures are legal and enforceable in the same fashion as a traditional signature.
2
Date
(mm/dd/yy)
TRIP CLAIM FORM - TIS - 06/2020
YES
NO
Claim Is Related To A Medical Situation
If claim is not related to a medical situation, do not complete this section.
To Be Completed By Patient/Guardian
Patient’s name Date of birth
(First, Last)
(mm/dd/yy)
Insured’s name Insured’s relationship to patient
(First, Last)
Policy purchase date
(mm/dd/yy)
To Be Completed By Physician (This information will be used for the adjudication of travel insurance claims.)
1. Was the patient medically stable for travel on the policy purchase date noted above?
(If NO, please provide medical records from the policy purchase date to the present.)
Date of treatment
a)
(mm/dd/yy)
b)
(mm/dd/yy)
c)
(mm/dd/yy)
(mm/dd/yy)
b)
c)
Describe the treatment/condition for this date
a)
(mm/dd/yy)
(mm/dd/yy)
b)
c)
Describe the treatment/condition for this date
a)
b)
c)
5.
Physician Name Specialty Phone Number Referred To/From
Date Of Referral
(check one)
a)
(First, Last)
(First, Last)
(First, Last)
From
To
(mm/dd/yy)
b)
From
To
(mm/dd/yy)
c)
From
To
(mm/dd/yy)
6. Did you advise the insured to cancel travel plans due
YES
If YES, what date did you advise to cancel?
to the patient’s condition?
NO
(mm/dd/yy)
Physician Remarks
Physician full address
Fax
Physician name
Taxpayer identication number
(First, Last)
Physician signature
Date
(mm/dd/yy)
3
Secondary Diagnosis
Date of treatment
a)
Provide the name and contact information for physicians involved in the treatment of the patient (including referrals)
3. When did symptoms irst appear or injury occur?
(mm/dd/yy)
4. Provide the dates of treatment, primary/secondary diagnosis and treatment provided.
Primary Diagnosis
2. Primary diagnosis
Secondary diagnosis
Claim Is Related To A Medical Situation
If claim is not related to a medical situation, do not complete this section.
Patient Consent Form
(First, Last)
(mm/dd/yy)
TRIP CLAIM FORM - TIS - 06/2020
Patient’s full name at time of treatment
Full address
Date of birth
Purpose of release:
ADJUDICATION OF TRAVEL INSURANCE CLAIM
Eective date of insurance coverage:
Signature of patient or authorized person Date
(mm/dd/yy)
Relationship and reason patient is unable to sign
4
(First, Last)
List all physicians consulted for this condition and hospitals where conned:
Name Address Phone Fax Dates
(mm/dd/yy - mm/dd/yy)
(First, Last)
(First, Last)
You are authorized to give Berkshire Hathaway Specialty Insurance Company and its aliates, reinsurers, agents, consumer reporting agency,
or independent claims administrator acting on behalf of Berkshire Hathaway Specialty Insurance Company, any information concerning
insurance coverage, medical care, advice, treatment or supplies, or any other information that may have bearing on the request for benets
submitted in conjunction with the travel-insurance policy.
Information to be released:
All medical records of the Patient for up to 180 days before the Eective Date of Insurance Coverage as shown above through the date of
this consent as shown below as applicable based on the patients age as outlined the policy. “Medical records” includes, without limitation,
diagnosis list, medication list, physician dictation, oce notes, physical therapy records, occupational therapy records, pathology reports,
cytology reports and the results of all laboratory tests.
Send to:
Berkshire Hathaway Specialty Insurance Company
P.O. Box 2986
Clinton, IA 52733-2986
Telephone: 855.205-6054 Fax: 715.303.6328
By signing below, I understand that:
1. The information in my health record may include information relating to a sexually transmitted disease, acquired immunodeciency
syndrome (AIDS), or human immunodeciency virus (HIV). It may also include information about behavioral or mental health services,
and treatment for alcohol and drug abuse.
2. I have the right to revoke this consent at any time by providing my written revocation to the facility where my records are kept.
3. A revocation will not apply to information that has already been released in response to this consent.
4. A revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.
5. Unless otherwise revoked, this consent will expire in six months.
6. Consenting to the disclosure of this health information is voluntary. I can refuse to sign this consent.
7. Any disclosure of information carries with it the potential for any unauthorized re-disclosure and the information may not be protected
by federal condentiality rules.
I authorize Berkshire Hathaway Specialty Insurance Company to disclose my health or claim information to any relevant source (e.g., airline,
tour operator, travel suppliers, etc.) for the purpose of obtaining recoveries or outstanding refunds after my insurance claim has been settled.
I hereby assign to Berkshire Hathaway Specialty Insurance Company any benets or recoveries obtained from these sources for losses
covered under this policy. I direct these sources to forward reimbursement to Berkshire Hathaway Specialty Insurance Company with regard
to these losses.
(mm/dd/yy)
TRIP CLAIM FORM - TIS - 06/2020
Claim Form Fraud Requirements
Mandatory – Please read and sign below.
All states other than those listed:
Any person who knowingly presents a false or fraudulent claim for payment of a 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.
Alaska
A person who knowingly and with intent to injure, defraud, or deceive an insurance
company les a claim containing false, incomplete or misleading information may be
prosecuted under state law.
California
For your protection, California law requires the following to appear on this form:
Any person who knowingly presents a false or fraudulent claim for the payment of a
loss is guilty of a crime and may be subject to nes and connement in state prison.
Colorado
It is unlawful to knowingly provide, false, incomplete or misleading facts or information
to an insurance company for the purpose of defrauding or attempting to defraud
the company. Penalties may include imprisonment, nes, denial of insurance and
civil damages. Any insurance company or agent of an insurance company who
knowingly provides false, incomplete, or company who knowingly provides false,
incomplete, or misleading facts or information to a policyholder or claimant for the
purpose of defrauding or attempting to defraud the policyholder or claimant with
regard to a settlement or award payable from insurance proceeds shall be reported
to the Colorado Division of Insurance within the Department of Regulatory Aairs.
Delaware
Any person who knowingly, and with intent to injure, defraud, or deceive any insurer,
les a claim containing any false, incomplete or misleading information is guilty of
a felony.
District of Columbia
It is a crime to provide false or misleading information to an insurer for the purpose
of defrauding the insurer or any other person. Penalties include imprisonment and/
or nes. In addition, an insurer may deny insurance benets if false information
materially related to a claim was provided by the applicant.
Florida
Any person who knowingly, and with intent to injure, defraud or deceive any
insurer, les a statement of claim or application containing any false, incomplete, or
misleading information is guilty of a felony of the third degree.
Idaho
Any person who knowingly, and with intent to defraud or deceive any insurer, les
a statement or claim containing any false, incomplete or misleading information is
guilty of a felony.
Indiana
A person who knowingly and with intent to defraud an insurer les a statement of
claim containing any false, incomplete or misleading information commits a felony.
Kentucky
Any person who knowingly and with intent to defraud any insurance company or
other person les a statement of claim containing any materially false information
or conceals, for the purpose of misleading, information concerning any fact material
thereto commits a fraudulent insurance act, which is a crime.
Louisiana
Any person who knowingly presents a false or fraudulent claim for payment of a 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.
Maine
It is a crime to knowingly provide false, incomplete or misleading information to
an insurance company for the purpose of defrauding the company. Penalties may
include imprisonment, nes or a denial of insurance benets.
Maryland
Any person who, with intent to defraud or knowingly facilitate a fraud against an
insurer, submits an application or les a claim containing a false or deceptive
statement may be guilty of insurance fraud.
Minnesota
A person who les a claim with intent to defraud or helps commit a fraud against an
insurer is guilty of a crime.
New Hampshire
Any person who, with a purpose to injure, defraud or deceive any insurance
company, les a statement of claim containing any false, incomplete or misleading
information is subject to prosecution and punishment for insurance fraud, as
provided in RSA 638:20.
New Jersey
Any person who knowingly les a statement of claim containing any false or
misleading information is subject to criminal and civil procedures.
New Mexico
Any person who knowingly presents a false or fraudulent claim for payment of a loss
or benet or knowingly presents false information in an application for insurance is
guilty of a crime and may be subject to civil nes and criminal penalties.
New York
Any person who knowingly and with intent to defraud any insurance company or
other person les an application for insurance or statement of claim containing any
materially false information, or conceals for the purpose of misleading, information
concerning any fact material thereto, commits a fraudulent insurance act, which is a
crime, and shall also be subject to a civil penalty not to exceed ve thousand dollars
and the stated value of the claim for each such violation.
Ohio
Any person who, with intent to defraud or knowing that he is facilitating a fraud
against an insurer, submits an application or les a claim containing a false or
deceptive statement is guilty of insurance fraud.
Oklahoma
Any person who knowingly, and with intent to injure, defraud or deceive any insurer,
makes any claim for the proceeds of an insurance policy containing any false,
incomplete or misleading information is guilty of a felony.
Pennsylvania
Any person who knowingly and with intent to defraud any insurance company or
other person xes an application for insurance or statement of claim containing any
materially false information or conceals for the purpose of misleading, information
concerning any fact material thereto commits a fraudulent insurance act, which is a
crime and subjects such person to criminal and civil penalties.
Tennessee
It is a crime to knowingly provide false, incomplete or misleading information to an
insurance company for the purpose of defrauding the company. Penalties include
imprisonment, nes and denial of insurance benets.
Washington
It is a crime to knowingly provide false, incomplete, or misleading information to an
insurance company for the purpose of defrauding the company. Penalties include
imprisonment, nes, and denial of insurance benets.
I ACKNOWLEDGE that I have read the fraud statement that applies to my state of residence. If my state
of residence is not listed, I acknowledge that I have read the “All States Other Than Those Listed”
Signature or typed name of the person completing form Date
(mm/dd/yy)
Person completing this form understands checking this agreement box and typing your name in the signature box above constitutes an
electronic signature and consent to le this acknowledgement electronically. Electronic signatures are legal and enforceable in the same fashion
as a traditional signature.
5
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Completed 24 September 2020

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