Fill - Free fillable iTravelInsured Medical Expense/Emergency Medical Evacuation Repatriation/Return of Remains (International Medical Group) PDF form

Medical & Dental Expense/Emergency Medical Evacuation/Repatriation/Return of Remains Claim Form

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To report a loss, return the required documentation along with your original, signed claim form to IMG® Claims. A delay in the processing of the claim will occur

if acceptable proof of loss or an incomplete claim form is submitted. Proof of loss must be submitted within 90 days of the date of loss. IMG reserves the right

to obtain further information needed to determine eligibility for benets and the proper payee.

INSURED INFORMATION

Insured’s Name (Last, First, Middle): Policy Number:

Mailing Address:

Email Address:

Cell Phone Number (With area code):

iTravelInsured Medical Expense/Emergency Medical

Evacuation Repatriation/Return of Remains

Claim Form

MEDICAL EXPENSES - REQUIRED DOCUMENTATION

 Doctor, Hospital, Ambulance, and/or Pharmacy

Original receipts/itemized billings for any out-of-pocket medical expenses incurred

 Proof of Payment

Credit card statements, cancelled checks, wire transfer receipts, or payment receipts for payments made to the service provider

 Medical Records

Copy of all medical documentation for services rendered to the insured person

 Medical Authorization

An authorization to release information to IMG® must be provided. A delay in the processing of the claim will occur if this is not provided

 Ocial Reports

A copy of the death certicate, police report, autopsy, coroner, toxicology, and ndings from any investigating entity is needed

Please print legibly and complete ALL SECTIONS (front and back) of this application. Send this form by secure methods only.

Address: IMG iTravelInsured® Claims, P.O. Box 3231, Farmington Hills, MI 48333-3231 USA

Call:

1.866.243.7524 or 1.317.655.9798; Fax: +1.317.927.6882

Email: iTravelClaims@imglobal.com

www.imglobal.com

PART 1. GENERAL INFORMATION

1. Full Name of Claimant: (If additional travelers, please attach complete a separate claim form)

Date of Birth:

___/___/___ (MM/ DD/YYYY)

Policy Number: Relationship to Insured:

Name of Travel Supplier (e.g. cruise line, airline, etc.):

Travel Agency’s Full Name: Travel Agent’s Name:

Telephone Number

(With area code):

Travel Agency’s Mailing Address: Email Address:

Initial Deposit Date Paid for Trip:

___/___/___

(MM/ DD/YYYY)

Final Payment Date:

___/___/___ (MM/ DD/YYYY)

Departure Date:

___/___/___ (MM/ DD/YYYY)

Schedule Return Date:

___/___/___ (MM/ DD/YYYY)

Actual Return Date:

___/___/___ (MM/ DD/YYYY)

Departure City: Destination (City, Country, or State):

Please check the box for benets requested:

 Medical/Dental Expenses  Evacuation/Repatriation/Return of Remains Expenses

Please note: by providing an email address and cell phone number on this form, you agree to electronic communications (including emails and SMS) about any claims that

you have submitted.

Medical & Dental Expense/Emergency Medical Evacuation/Repatriation/Return of Remains Claim Form

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PART 2. EXPLANATION OF ACCIDENT, SICKNESS, OR INJURY

Describe in detail what occurred:

Please list the expenses related to the loss. Attach additional sheets if necessary:

Insured Name Medical Provider Date of Service (MM/ DD/YYYY) Charge Amount (List currency)

___/___/___

Less payments by other coverage:

Total amount of claim:

Reminder: Any insurance is in excess of other insurance or indemnity. If at the time of the loss there is any other insurance or indemnity, the contract only oers reimbursement for

the excess of the loss amount above the amount of other insurance or indemnity. Insureds must rst le a claim with the other carrier and forward a copy of that carrier’s decision.

PART 3. MEDICAL INFORMATION

Patient’s Name:

Date Symptoms First Noticed:

___/___/___

(MM/ DD/YYYY)

Nature of Illness:

Date of First Consultation:

___/___/___

(MM/ DD/YYYY)

Describe onset, diagnosis, and treatment:

For injury, describe injury:

Date of First Consultation:

___/___/___

(MM/ DD/YYYY)

How and where did the accident occur:

If hospitalized, hospital name, website, and address:

Dates of Connement:

___/___/___

(MM/ DD/YYYY)

From: To:

Name and address of treating physician: Telephone Number (With area code):

Fax Number (With area code):

Medical & Dental Expense/Emergency Medical Evacuation/Repatriation/Return of Remains Claim Form

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PART 4. OTHER COVERAGE

Do you have any other insurance or coverage related to the loss (e.g. medical, travel, etc.)?

 Yes  No

Do you have any other travel insurance coverage?

 Yes  No

Did you report the loss to any other insurance company?

 Yes  No

If Yes, which company:

Name of Company:

__________________________________________

Address: _____________________________________

____________________________________________

2. __________________________________________

Address: _____________________________________

____________________________________________

3. __________________________________________

Address: _____________________________________

____________________________________________

(Please attach a separate sheet if necessary)

Policy/Certicate Number:

______________________________

Telephone Number

(With area code):

________________

Website:

_______________

________________

Medical & Dental Expense/Emergency Medical Evacuation/Repatriation/Return of Remains Claim Form

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AUTHORIZATION

Signature of Insured/Claimant:

X ___________________________________________________________________

Date: ___/___/___ (MM/ DD/YYYY)

The undersigned authorizes any health plan, healthcare provider, healthcare

professional, MIB, federal, state or local government agency, insurance or

reinsuring company, consumer reporting agency, employer, benet plan, or

any other organization or person that has provided care, advice, diagnosis,

payment, treatment, or services to the insured or on the insured’s behalf, has

any records or knowledge of the insured’s health, has any information available

as to diagnosis, treatment and prognosis with respect to any physical or mental

condition and/or treatment of the insured, and any non-medical information

about the insured, to disclose the insured’s entire medical record, le, history,

medications, and any other information concerning the insured and to give

any and all such information to the insured’s agent of record and authorized

representatives of the insurer, IMG, and their aliates, and subsidiaries.

This information will be used to evaluate claims for benets. Individuals have

the right to refuse to sign the authorization without negative consequences to

treatment or plan enrollment, except IMG will not be able to administer claims,

determine benet eligibility, or issue payments. The authorization is valid for the

term of the insurance contract or plan under which a claim has been submitted.

The undersigned understands that the insured has the right to receive a copy

of this authorization upon request and revoke the authorization at any time in

a written communication to IMG. A copy of this shall be as valid as the original.

The undersigned acknowledges and understands there is the potential for the

information to be subject to redisclosure by the recipient and to no longer be

protected by applicable privacy and condentiality laws.

The undersigned represents and warrants information or documents provided

to IMG by the undersigned prior to and after the date of the application for

insurance and the facts and other matters contained in the foregoing are

true and accurate to the best of the undersigned’s knowledge and belief. The

undersigned understands and agrees:

1) Any insurance coverage or benet is contingent upon any statement made

to IMG as being complete and correct

2) Benets under any contract will be paid only if IMG decides the applicant

is entitled to them

CLAIM FORM FRAUD STATEMENT

FOR RESIDENTS OF ALL STATES OTHER THAN THOSE LISTED BELOW:

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.

ARIZONA: For your protection Arizona law requires the following statement to

appear on this form. Any person who knowingly presents a false or fraudulent

claim for payment of a loss is subject to criminal and civil penalties.

ALASKA and 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, incomplete or misleading information or

conceals, for the purpose of misleading, information concerning any fact

material thereto commits a fraudulent insurance act, which is a crime and 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 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 agencies.

FLORIDA: WARNING: Any person who knowingly and with intent to injure,

defraud, or deceive any insurer les a statement of claim or an 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

insurance company, les a statement of claim containing any false, incomplete,

or misleading information is guilty of a felony.

MARYLAND: Any person who knowingly or willfully presents a false or

fraudulent claim for payment of a loss or benet or who knowingly or willfully

presents false information in an application for insurance is guilty of a crime and

may be subject to nes and connement in prison.

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 penalties.

PENNSYLVANIA: 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 subjects such person

to criminal and civil penalties.

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.

TENNESSEE and VIRGINIA: 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.

TEXAS: Any person who knowingly presents a false or fraudulent claim for

payment of a loss is guilty of a crime and may be subject to nes and connement

in state prison.

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.

Version 0820CM00501384A210428

Wire Transfer Authorization and Agreement

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Message about electronic transmissions: Electronic transmissions via email or fax are not secure and may be intercepted by unauthorized individuals. Please send your

claim form by secure means. If you chose to send by insecure means, such as unsecured email, you agree to accept any and all resulting risk.

If sending funds outside of the United States, there may be additional, special fund transfer requirements for international transfers.

Please do not send the Terms & Conditions. Please keep this page for your ﬁles. For questions, errors, or issues regarding the transaction, visit

www.imglobal.com or call 1.317.655.4500.

ACH Transfer Authorization

and Agreement Form

INSURED (REQUESTOR) INFORMATION

Name of Insured:

Date of Birth:

___/___/___ (MM/ DD/YYYY)

Insured ID Number:

Street Address (No P.O. Box):

City: State/Province: Postal Code: Country:

Telephone Number/Email: Wire sent on behalf of (if applicable):

WIRE TRANSFER CURRENCY SELECTIONS

Check destination:

 International (outside U.S.)

 Domestic (inside U.S.)

For international wires, funds will be sent in the currency of the destination country, where available. If you wish for

the funds to be sent in U.S. dollars (Funds will be converted by local bank, unless recipient has a U.S. dollar account), please

indicate by checking this box: 

Currency type if international (name of country and unit):

BENEFICIARY (“RECIPIENT”) INFORMATION

Name: Telephone Number/Email:

Address shown on your bank account (no P.O. Box):

City: State/Province: Postal Code: Country:

SWIFT Code

(Required for international payments):

International Bank Account Number (IBAN)

(Required if sending Euros):

BENEFICIARY BANK (“RECIPIENT BANK”) INFORMATION

Bank Name:

Branch address linked to your account:

City: State/Province: Postal Code: Country:

Account Number: ACH Routing Number:

INTERMEDIARY BANK INFORMATION (if applicable)

Bank Name:

Branch address linked to your account:

City: State/Province: Postal Code: Country:

Account Number: ACH Routing Number:

SPECIAL INSTRUCTIONS (i.e. If 100% of the beneﬁts owed should not be transferred to the above Beneﬁciary bank)

REQUESTOR AUTHORIZATION: By signing below, I request for an accommodation from and for Company to execute the above funds transfer

instruction up to the amount of beneﬁts owed in accordance with under the insurance contract for funds transfers set forth in this agreement. I

understand and acknowledge Recipients may receive less due to fees charged by the Recipient’s bank and taxes, and any cancellation must occur

within 30 minutes of sending the request, unless the funds have already been picked up or deposited.

Authorized Signature and Date: X_______________________________________________

Authorized Signature and Date: ___/___/___ (MM/ DD/YYYY)

Please print legibly and complete ALL SECTIONS (front and back) of this form. Mail, fax, or email completed form to:

Address: IMG iTravelInsured® Claims, P.O. Box 3231, Farmington Hills, MI 48333-3231 USA,

Call: 1.866.243.7524 or 1.317.655.9798; Fax: +1.317.655.4505

Email: itravelclaims@itravelinsured.com

www.itravelinsured.com

Wire Transfer Authorization and Agreement

Page 2 of 2

Terms and Conditions for Funds Transfers

By requesting a funds transfer order with International Medical Group, Inc., its aﬃliates, or its subsidiaries (the “Company”), you agree to the following:

Reliance by Company. Company may rely on the information on the form received by it in making your funds transfer. Any errors in the information, including

misidentiﬁcation of Beneﬁciary(ies), Recipient(s), incorrect or inconsistent account names and numbers, identifying numbers of the intermediary bank or Beneﬁciary

Bank, and misspellings, are your responsibility. If you identify a Beneﬁciary or other entity by name and account or any other number, payment may be made on the

basis of the number and your payment will be ﬁnal even if the number you provided does not correspond to your Beneﬁciary or other entity that you have identiﬁed.

Bank Fees. Your ﬁnancial institution may be authorized to debit your account for any fees, costs, or charges related to your funds transfer order. You may have further

authorized your ﬁnancial institution to charge your account a service fee for each funds transfer order you place in accordance with its fee schedule in eﬀect from

time to time

Transfer of Beneficiary Bank. When you place an order with Company for a funds transfer, you must select a ﬁnancial institution as the Beneﬁciary Bank for the

transfer. For transfers within the United States, the Beneﬁciary Bank must be a member of the Federal Reserve System or a correspondent bank of such a member,

or a Clearing House Interbank Payment System (CHIPS) member. You may request that the funds either be deposited to a particular account at the Beneﬁciary

Bank or that they be held at the Beneﬁciary Bank for your Beneﬁciary. The Beneﬁciary Bank will be responsible for following your instructions and for notifying the

Beneﬁciary that the funds are available. After the funds are transferred to the Beneﬁciary Bank, they become the property of the Beneﬁciary Bank. The Beneﬁciary

Bank is responsible to locate, identify, and make payment to your Beneﬁciary. If your Beneﬁciary cannot be properly identiﬁed, the funds may be returned.

Currency of Transfer. Funds transfers to beneﬁciaries within the United States are made only in U.S. dollars. For funds transfers to beneﬁciaries and Beneﬁciary

Banks in other countries, unless you choose to send U.S. dollars, the transfer will be made in the currency of that country. For such funds transfers, the ﬁnancial

institution will convert your U.S. dollar payment to the local currency at that ﬁnancial institution’s exchange rate in eﬀect at that time. The exchange rate usually

includes a commission to the ﬁnancial institution for exchanging the currency. Because of the laws of some countries in which Beneﬁciary Banks are located, if you

request a transfer in U.S. dollars the Company cannot guarantee that your Beneﬁciary will be able to receive U.S. dollars. If your transfer must be converted to the

local currency, the Beneﬁciary Bank may charge a fee for this exchange. Regardless of the currency transferred, the actual amount that your Beneﬁciary receives may

be reduced by charges imposed by the Beneﬁciary Bank, including those for exchanging currency.

Means of Transfer. Company uses a variety of banking channels and facilities to make funds transfers, but will ordinarily use electronic means. The Company may

choose any conventional means that the Company considers suitable to transfer your funds to your Beneﬁciary. Because the Company does not maintain banking

relations with every bank, the Company sometimes uses one or more intermediary banks to transfer your funds to the Beneﬁciary Bank. After the Company transmits

your order to an intermediary bank, that bank is responsible to complete your order.

Recalls/Amendments. You may recall or amend your funds transfer order only if the Company receives your request prior to our execution of the funds transfer

order and at a time that provides Company a reasonable opportunity to act upon that request. If your funds transfer order has been executed by Company, the order

can be recalled and amended only if the Beneﬁciary Bank consents to such a request. Company will not be liable to you for any loss resulting from the failure of the

Beneﬁciary Bank to recall or amend your funds transfer order. If you decide you want to recall your funds transfer order and your order has already been executed by

Company, you will ﬁrst have to check with the Beneﬁciary Bank to determine whether the Beneﬁciary Bank can return your funds. If the Beneﬁciary Bank conﬁrms

that the funds are returnable and the funds are returned to Company by the Beneﬁciary Bank, Company may then send a check for the funds to you. The amount

that is returned to you may be less than you originally transferred because of service charges of the Beneﬁciary Bank or Company. Your check will be in U.S. dollars.

If your funds transfer was in a foreign currency, your U.S. dollar check will be at the exchange rate on the date of the check.

Rejection of an Order. The Company reserve the right to reject your funds transfer order. The Company may reject your order if you have insuﬃcient information,

the order does not comply with applicable laws, the order is inconsistent with rules and regulations of the ﬁnancial institutions involved, if your order is incomplete

or unclear, or if the Company is unable to fulﬁll your order for any other reason including but not limited to force majeure events.

Delays, Non-Execution of Funds Transfer Order. While the Company will handle your funds transfer order as expeditiously as possible, you agree that Company

will not be responsible for any delay, failure to execute, or misexecution of your order due to circumstances beyond Company’s reasonable anticipation or control–

including without limitations any inaccuracy, interruption, delay in transmission, or failure in the means of transmission, whether caused by strikes, power failures,

equipment malfunctions, or acts or omissions of any intermediary bank or Beneﬁciary Bank. Company MAKES NO WARRANTIES, EXPRESS OR IMPLIED–INCLUDING

THE FAILURE OF ANY INTERMEDIARY BANK OR Beneﬁciary BANK TO CREDIT YOUR Beneﬁciary WITH THE AMOUNT OF THE FUNDS TRANSFER AFTER RECEIPT OF SAME

WITH RESPECT TO ANY MATTER.

Cut-Off Time For Executing Your Funds Transfer Order. If your funds transfer order is received by Company at or after its established cut-oﬀ hour for receipt of

funds transfer orders, the earliest your funds transfer order can be executed is the next banking day following receipt of all required information.

Claims. You agree that within one hundred eighty (180) days after you receive notiﬁcation that your funds transfer order has been executed, you will tell Company

of any errors, delays or other problems related to your order. Company will determine whether an error occurred within 90 days after you contact Company and

any error will be corrected promptly. Company will tell you the results within 3 business days after completing the investigation. If Company decides there was no

error, a written explanation will be sent to you. You may ask to appeal an adverse decision by supplying copies of any documents related to the transaction. If your

funds transfer order is delayed or erroneously executed as a result of Company’s error, Company’s sole obligation to you is to pay via check such amounts as may be

required by applicable law. In no event shall Company be responsible for any consequential or incidental damages or expenses in connection with your order. Any

claim for interest payable by Company shall not be at any published savings account rate in eﬀect within the state of execution of the funds transfer. In any event,

if you fail to notify Company of any claim concerning your funds transfer order within one year from the date that you receive notiﬁcation that your order has been

executed, any claim by you will be barred under applicable law.

Governing Law. The Agreement will be governed by the laws of the state of Indiana which is the location through which you initiated this funds transfer and United

States federal law as applicable.

Indemnity. In consideration of the agreement by Company to act upon funds transfer instructions in the manner provided in this Agreement, you agree to

indemnify and hold Company harmless from and against any and all claims, suits, judgments, executions, liabilities, losses, damages, costs, and expenses–including

reasonable attorney’s fees–in connection with or arising out of Company acting upon those funds transfer instructions pursuant to this Agreement. This indemnity

will be eﬀective to relieve and indemnify Company against its negligence or misconduct.

IMG aﬃliates and subsidiaries currently include the following companies: iTravelInsured, AkesoCare Management, IMG Europe, International Medical Administrators, Inc.,

Global Response Ltd., and The IMG Foundation.

Version 0719IN01200789A190725

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