Fillable iTravelInsured Travel Delay/ Missed Connection Claim Form (International Medical Group)

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iTravelInsured Travel Delay/ Missed Connection Claim Form (International Medical Group)

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Travel Delay Claim Form
Page 1 of 4
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 unacceptable proof of loss or an incomplete claim form is submitted. Proof of claim 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.
iTravelInsured Travel Delay/
Missed Connection Claim Form
The following documentation will initially be required to begin processing of your claim:
The fully completed claim form, signed, and dated
A copy of the complete trip itinerary including all transportation details and ticket information
A copy of the complete altered itinerary issued by the travel supplier or common carrier due to the delay, including reservation numbers
Documentation from the travel supplier and common carrier (airline, cruise line, etc.) indicating the reason and length of the delay
Documentation verifying any refunds, reimbursement, credits, or vouchers issued by the travel supplier and common carrier following the delay
Itemized receipts for additional expenses incurred due to the delay
If the delay was caused by the loss or theft of passports or travel documents, a copy of a report led with the governmental entity is required
If the delay was due to sickness, injury, or death, medical documentation is required.
If losses are being claimed for nonrefundable pre-paid, unused portions of the trip that were lost due to the delay or missed connection, the
following documentation will also be required:
Proof of payment for the unused portion of your covered trip
Documentation from the travel supplier and common carrier to verify portions of the trip that were not used due to the delay or missed connection
Documentation from the travel supplier and common carrier verifying no refund, reimbursement, credit, or voucher was issued for the unused portion of
the covered trip.
PRIMARY CLAIMANT INFORMATION
Insured’s Name (Last, First, Middle): Policy Number:
Mailing Address:
Email Address:
Cell Phone Number (With area code):
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
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.
Travel Delay Claim Form
Page 2 of 4
PART 1. GENERAL INFORMATION
1. Full Name of Claimant: (For additional claimants, please attach additional sheets)
Date of Birth
___/___/___ (MM/ DD/YYYY)
Policy Number: Relationship to Insured:
2. Full Name of Claimant:
Date of Birth
___/___/___ (MM/ DD/YYYY)
Policy Number: Relationship to Insured:
3. Full Name of Claimant:
Date of Birth
___/___/___ (MM/ DD/YYYY)
Policy Number: Relationship to Insured:
4. Full Name of Claimant:
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:
PART 2. EXPLANATION OF DELAY OR MISSED CONNECTION
Name of Airline: Flight Number:
Describe in detail what occurred:
Original Scheduled Departure Date:
___/___/___
(MM/ DD/YYYY)
Actual Departure Date and Time:
___/___/___
(MM/ DD/YYYY)
Actual Arrival Date and Time:
___/___/___
(MM/ DD/YYYY)
Total Hours of Delay:
___/___
(Hours/ Minutes)
Did you receive refunds, reimbursement, credits, or vouchers? Yes No If yes, the amount: $
Please list any additional expenses incurred due to the Trip Delay/Missed Connection. Please use a separate sheet of paper for any additional
expenses claimed. Claims cannot be processed without proof of loss.
Type of Expense Incurred (Lodging, meals, etc.) Date Incurred (MM/ DD/YYYY)
Amount Paid (Please indicate currency in which
expense was incurred)
Total Amount of Delay/Missed Connection Losses:
Travel Delay Claim Form
Page 3 of 4
PART 3. 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 travel other insurance coverage?
Yes No
Did you report the loss to any other insurance company?
Yes No
If Yes, which company:
Name of Company:
1.
__________________________________________
Address: _____________________________________
____________________________________________
2. __________________________________________
Address: _____________________________________
____________________________________________
3. __________________________________________
Address: _____________________________________
____________________________________________
(Please attach a separate sheet if necessary)
Policy/Certicate Number:
______________________________
______________________________
______________________________
Telephone Number
(With area code):
________________
________________
________________
Website:
_______________
_______________
________________
Travel Delay Claim Form
Page 4 of 4
AUTHORIZATION
Signature of Insured/Claimant: Date:
___/___/___ (MM/ DD/YYYY)
Signature of Insured/Claimant: Date: ___/___/___ (MM/ DD/YYYY)
Signature of Insured/Claimant: Date: ___/___/___ (MM/ DD/YYYY)
Signature of Insured/Claimant: Date: ___/___/___ (MM/ DD/YYYY)
The undersigned authorizes any health plan, health care provider, health
care 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 0820CM00501382A210428
Wire Transfer Authorization and Agreement
Page 1 of 2
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.
1
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.)
1
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_______________________________________________
2
nd
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.
2
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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iTravelInsured Travel Delay Missed Connection Claim Form (International Medical Group)

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Completed 14 June 2021

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