Form Instructions Step 1: Your Details

Form Instructions

Step 1: You must complete all sections of this form to assist with the assessment of your claim

Step 2: Ensure the Declaration page is signed and witnessed

Step 3: Attach documents that are reasonably required to support your claim

Step 4: Return your form and supporting documents to the below addresses:

Important Information:

• If an eligible person wishes to claim any of these benefits, they will be bound by the eligibility criteria, terms, condition s, limits

and exclusions contained in the insurance information booklet in use as at the date of the loss event.

• Please do not email copies of your credit card statement - if you are required to provide a credit card statement for your claim,

a Claims Consultant will guide you through the process of sending these documents via post.

• We do not keep hard copies of your personal information. Please only provide copies of documents and retain the originals for

your records.

Step 1: Your Details

Title Full name

Policy/reference number Date of birth

Phone Mobile

Address

Suburb State Postcode

Please confirm how you would like to receive any written correspondence: Email Post

Authorisation

If you wish to give authority for another person to act on your behalf in respect to this claim you must complete the followi ng

details. Authority may be given to any person/s which may include family members, otherwise we will not be able to give any

information about your claim to any other person. It is important to note that a travel agent cannot manage a claim on behalf of

the customer.

I authorise the following listed person to act on my behalf in relation to this claim:

Name Date of birth

Relationship Phone number

Payment details

Please provide your bank details below for a direct credit to your nominated bank account. If you do not provide the followin g

details, we will post a cheque. If we are required to make a payment on your behalf, we will contact you to discuss your

payment of any applicable excess.

Please note we cannot credit a credit card/debit card.

Account Name: Bank name

BSB Number Account number

Email your form to us

Cardclaims@allianz-assistance.com.au

Mail your form to us

Locked Bag 3014, TOOWONG DC, QLD 4066

Step 2: Trip Details

Q1. Date of booking your travel: Q2. Date your journey was cancelled (if applicable):

Q3. Date of planned departure: Q3. Date of your original return

If applicable:

Q5. Date of rescheduled departure: Q6. Date of rescheduled return (if applicable)

Step 3: Credit Card Details

Q1. First six digits of your credit card Last four digits of your credit card

Q2. Name on card

Q3. Financial Institution

Q4. Card name/type (as outlined on statement)

Q5. Are you a cardholder for this credit account? Yes No

If no, please answer the following questions:

What is the relationship between you and the cardholder? Spouse Dependent Other

If other, please explain

Were you with the cardholder at the time of the incident? Yes No

Do you permanently reside with the cardholder? Yes No

Q6. Please detail purchases made on your card for your journey:

Date of purchase

Description of expense

Amount charged

(Currency)

DD/MM/YYYY

Flights

500 AUD

Q7. Have you purchased your flight ticket? Yes No

If yes, please answer the following questions:

Date of purchase

Was this purchased on your eligible credit card? Yes No

Step 4: GST

Q1. Are you registered for GST purposes? Yes No

Q2. Are you entitled to claim an Input Tax Credit? Yes No

If yes, please outline the percentage of the GST entitled to claim

Step 5: Claims History

Q1. Have you made any travel insurance or home and contents insurance claims in the past 5 years ? Yes No

If yes, please answer the following:

How many previous claims?

What have you claimed for?

Please describe what you have claimed before and include claim and policy numbers

Step 6: Details of Other Insurance

Q1. Have you lodged or do you intend to lodge a claim for this event elsewhere? Yes No

Q2. Have you received compensation from any other party in relation to this event? Yes No

If yes, please provide full details

Q3. Do you have any other insurance policies that may cover the loss you are claiming for? Yes No

If yes, please provide the following

Name of insurer

Policy number

Step 7: Details of Event & Information Required

Event Details

Date of Event/Incident:

Please provide a detailed summary outlining the event causing the claim:

Please ensure that you complete the below details for all benefits that you are claiming against as a result of the

event outlined above.

Luggage / Luggage Delay

If you are entitled to be reimbursed by the bus line, airline, shipping line or rail authority you were travelling on when th e loss,

theft, misplacement or damage occurred, please submit your claim with them first. In the event that the carrier only settles a

portion of your claim, your policy may provide further cover.

Documents that are reasonably required to support your claim:

• Tax Invoice for your travel arrangements showing the last 4 digits of your credit card

• Original Travel Itinerary/s detailing costs (e.g. transport, accommodation, tours etc.), plus amended itinerary if

applicable.

Please note: your travel agent can assist you in gathering this information from individual providers. If you did not

book through a travel agent simply contact the individual providers you booked through.

• Invoices and/or receipts for items you are claiming

• Loss report from the police or other official body (e.g. Airline, Tour Operator, Hotel etc.)

• If the item/s claimed are damaged: Written report confirming the cost to repair the item. If the item is not repairable

then this must be outlined within the report.

• If the items are delayed: Written confirmation from the travel provider confirming the length of delay (e.g. Airline, Tour

Operator, Hotel etc.)

If you do not make all reasonable effort to provide this information, it may delay the assessment of your claim.

Were your items lost, damaged or delayed? Lost Damaged Delayed

If your items were lost or damaged, please provide the following:

Were all the missing / damaged articles owned by you? Yes No

If no, please detail:

If your items were delayed, please provide the following:

Date your luggage was delayed Date your luggage was returned

What compensation was received from the carrier?

Personal property or

replacement item claimed

Store where items

was purchased

Date of

purchase

Purchase

price

Amount

claimed

Proof of purchase

attached?

e.g. Suit Case

Bag Store Name

DD/MM/YYYY

$100 AUD

$50 AUD

Yes / No

Cancellation / Additional Expenses / Travel Delay

Documents that are reasonably required to support your claim:

• Tax Invoice for your travel arrangements showing the last 4 digits of your credit card

• Original Travel Itinerary/s detailing costs (e.g. transport, accommodation, tours etc.), plus amend ed itinerary if

applicable.

• Written documentation outlining the cause of your cancellation and/or rescheduled travel arrangements and/or

travel delay. (e.g. a letter from your airline or tour provider confirming the cause of the cancellation/delay)

• Written confirmation from the travel provider (e.g. airline, cruise, travel agent, online booking etc.) that the travel

arrangements were cancelled and cannot be used in the future (e.g. via credit shell, transfer or refund).

• Terms and conditions detailing refund or credit entitlements from the travel provider (e.g. airline, cruise, travel

agent, online booking etc.)

Please note: your travel agent can assist you in gathering this information from individual providers. If you did not

book through a travel agent simply contact the individual providers you booked through.

If your claim is due to a Medical Condition:

• Please ensure that the attached medical certificate is completed by the patient’s usual treating general practitioner

• Any medical or hospital reports relating to the medical condition causing this claim. More information regarding

these reports can be found on the attached medical certificate.

If you do not make all reasonable effort to provide this information, it may delay the assessment of your claim.

Please list each original travel arrangement (e.g. flight, accommodation etc.) including any replacement travel arrangement i f

applicable individually in the table.

Date of expense

Description of cost

Type of

expense

Amount paid

Refund / credit

value

Amount claimed

DD/MM/YY

e.g. Return Flights Perth to Brisbane

Original OR

Additional

$1000 AUD

$200 AUD

$800 AUD

Funeral Expenses

Documents that are reasonably required to support your claim:

• Tax Invoice for your travel arrangements showing the last 4 digits of your credit card

• Original Travel Itinerary/s detailing costs (e.g. transport, accommodation, tours etc.), plus amended itinerary if

applicable.

Please note: your travel agent can assist you in gathering this information from individual providers. If you did not

book through a travel agent simply contact the individual providers you booked through.

• A copy of the Death Certificate

• Details of Executor of Estate (e.g. a copy of the will)

• Proof of payment for the funeral expenses incurred (e.g. receipts with the last four digits of the eligible credit card)

• Any supporting documentation that is reasonably required to support your claim

If you do not make all reasonable effort to provide this information, it may delay the assessment of your claim.

Further information may be requested after assessment of your claim.

Date of expense

Claim description

Claim amount

Declaration

• I/we declare that all statements and particulars stated on this claim form and all documents submitted are true and correct.

• I/we will use my best endeavours and give all reasonable assistance and co-operation to AWP Australia Pty Ltd trading as

Allianz Global Assistance in the assessment of this claim.

• I/we acknowledge that Allianz Global Assistance relies upon the truthfulness of the statements and particulars and

documents submitted in respect of this claim.

• I/we have not withheld any material information connected with this claim that will inhibit the ability of Allianz Global

Assistance to make a fair and reasonable assessment of this claim.

• I/we acknowledge and agree that Allianz Global Assistance may collect, use, and disclose my personal information

including sensitive information in accordance with its Privacy Policy; (see the Privacy section below).

• I/we assign to Allianz Global Assistance all rights of recovery against any person or organisation and will cooperate to

secure such rights.

Authority

I authorise AWP Australia Pty Ltd trading as Allianz Global Assistance to obtain and collect any information relating to me

(including personal information) which Allianz Global Assistance in its absolute discretion considers necessary to assess and

investigate any aspect of this claim, including but not limited to information about any medical treatment and its cost, medi cal

history, my financial circumstances, and the facts and circumstances which resulted in or are connected with this claim.

I authorise any person, corporation, institution whether public or private, Medicare, doctors, hospitals, medical facilities, and

any entity whatsoever that holds information about me (including 'personal information' as defined in the Privacy Act 1988

(C'th)) to release and provide such information to Allianz Global Assistance which Allianz Global Assistance in its absolute

discretion requests. In the event I am deceased, un-contactable, or have no legal capacity, I authorise Allianz Global

Assistance to pay any policy benefits payable under my policy to my estate or personal representatives, and in the event there

is no will or it cannot be produced or there are no personal representatives lawfully appointed, to my next of kin.

Privacy

By providing your personal information to us (whether by yourself or through someone on your behalf), you agree and consent

to the collection, use, and disclosure of your personal information as set out in our Privacy Policy available on request

(telephone 1800 023 767) or on the web at http://www.allianzpartners.com.au/privacy-and-security.

For example, we may disclose your personal information to third parties (some of whom may be located overseas) such as

external claims handlers and data collectors who assist us manage claims, other insurers, travel agents, your broker, medical

practitioners, your family members, loss adjusters and intermediaries, investigators and the Insurance Reference Service

(IRS), and to our business partners to offer you products and services in which you may be interested. You have the rig ht to

seek access to your personal information at any time. Without your consent to our Privacy Policy, we may not be able to

provide our services to you

Internal Dispute Resolution

Allianz Global Assistance provides an internal dispute resolution process should any dispute arise. Please feel free to ask for

details. If you are not satisfied with the outcome of this process, we will advise you how to contact the insurance industry's

external independent complaints scheme.

Fraud

Insurance fraud places additional costs on honest policyholders. Fraudulent claims force insurance premiums to rise. We

encourage the community to assist in the prevention of insurance fraud. You can help by reporting insurance fraud. All

information will be treated as confidential and protected to the full extent under law. Report insurance fraud by calling Allianz

Global Assistance on 1800 453 937

Signature of claimant Signature of witness

Name of claimant Name of witness

Date Date