TATA-AIG GENERAL INSURANCE COMPANY LIMITED
AHURA CENTER, 4TH FLOOR,
MAHAKALI  CAVES ROAD,
ANDHERI (E), MUMBAI - 400 093
OVERSEAS TRAVEL INSURANCE CLAIM FORM
Print
Please contact our 24-hour helpline (our Assistance Center) on Ph: +91-11-3352707, Fax: +91-11-3352701
email: delhi.tata-aig@internationalsos.com
Failure to call our Assistance Company on 24-hour helpline, in respect of Medical Accident & Sickness Claims shall invalidate  your claim,
if any. Please note, the first US$100 of your expenses is deductible, and must be borne by you.
1. This is a One Call Claim Form, except for Accidental Death & Dismemberment (ADD). For ADD, we shall provide a separate Claim Form upon notification.
2.  Issuance of the form is not an admission of liability or a waiver of terms, conditions & exceptions of the insurance contract.
3.  No claim under Accident & Sickness Section will be admitted without Doctor's Report as per format (Attending Doctor's Report - Page 4)
4.  Please answer all questions completely. In case of insufficient space, please attach an additional sheet.
5.  Please attach all bills, receipts, credit card slips pertaining to your claim.
Certificate/ Policy No._____________				Period From ________________  to: ________________
DETAILS OF INSURED
Name : _____________________________________________					Phone Nos. ___________________________________
Address:_______	____________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Relationship with Insured person:
DETAILS OF PATIENT/ INSURED PERSON
Name : ______________________________________________					Phone Nos. ___________________________________
Permenant Address:____________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Date of Birth: ______/______/_______					Sex:  M / F
ISOS Ref. No.: _______________________________					Passport No.: ________________________
Date of Departure: ___/___/___			Flight No. _________		From __________________ to ____________________
Date of Arrival:      ___/___/___			Flight No. _________		From __________________ to ____________________
Please indicate whether claim is in respect of:        Accident & Sickness          Hospitalisation Benefit         Travel Delay            Baggage Loss
Baggage Delay                   Loss of Passport           Personal Liability             Hijack
	Please complete the Section relevant to your claim.
LOSS/DELAY OF CHECKED BAGGAGE
Describe when & where the loss/delay took place: ___________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
State the extent of Loss: ________________________________________________________________________________
Name the common carrier: ___________________________
1.  Flight No. ___________________ From _______________________________ to _______________________________
2.  Flight No. ___________________ From _______________________________ to _______________________________
Has the common carrier been notified at the time of loss?         Yes           No						Airline Reference No. _________________
Details of compensation received from carrier: _______________________________________________________________
Scheduled date/time of Arrival:___/___/____; __:__hrs.        Actual date/time when bags delivered :___/___/____; __:__hrs
No. of Hours delayed :__________
Item Purchased/Lost *				Date of Purchase		Place		Cost
							TOTAL
				Less Compensation received from Airline:
						Net Amount:
* In case of Delay, please provide details of purchases made
* In case of Loss, please provide details of items lost.
LOSS OF PASSPORT
Please provide details of the incident i.e. when, where and how it happened:_______________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Details of Police Report (please attach copy): No:_____________________Date: ___________ Place: ________________
Details of Expense incurred				Date		Place		Amount
							TOTAL
TRAVEL DELAY
Flight No. ________________  Date____/____/______   From _______________________ to________________________
Scheduled time of Departure:___________   Actual time of Departure: ____________  No. of Hours delayed:____________
Whether accomodation & boarding provided by carrier:         Yes         No
Details of Expense incurred				Date		Place		Amount
							TOTAL
HIJACKING
Flight Details: No. _____________________  From __________________________________ to ______________________
Scheduled Date & time of Departure: ______________________ Scheduled date & time of arrival:_____________________
Date and time of Hijack: __________________________  Date & time Returned: _____________________________
Please provide details of incident: ________________________________________________________________________
_____________________________________________________________________________________________________
PERSONAL LIABILITY
Please provide details of injury/ property damaged: ___________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Details of Amount Claimed: ______________________________________________________________________________
Any other information you would like us to have: _____________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
MEDICAL ACCIDENT & SICKNESS BENEFIT
If accident, details of accident i.e. how, when, where it took place:_______________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Date:_________________________________				Place: __________________________________________
If sickness, state nature and diagnosis, and advise when & where symptoms first occurred: _________________________
_____________________________________________________________________________________________________
Date:_________________________________				Place: __________________________________________
Name & Address of consulting physician: __________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Have you ever been treated for this illness before:					Yes           No
If yes, provide name & address of consulted physician: _______________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Provide name & address of your family physician: ___________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Provide name of any prescription medicine you are presently taking: ____________________________________________
Indicate other health insurance coverages, including name, address, policy number & certificate number of insurer:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Details of treatment				In/ Out Patient		Charges (Currency)		Rupees
				From	To
							Paid
							Outstanding
							TOTAL DUE
Whether ISOS/ Assistance Co. was contacted:       Yes        No.    If Yes, Reference No. __________________________
If No, give reasons:_____________________________________________________________________________________
_________
_____________________________________________________________________________________________________
AUTHORIZATION
I hereby authorize any hospital, physician, or other person who has attended or examined me, to furnish to the company,
or its authorized representative, any and all information with respect to any illness or injury, medical history, consultation,
prescriptions or treatment and copies of all hospital or medical records, a photostat copy of this authorization  shall be
considered as effective and valid as the original.
	Date:			Place:
	Signature of insured :_________________________________________________
Attending Doctor's Report
Patient's Name: ____________________________________________________   Age: _______     Sex:                M / F
Address: ____________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Date contacted: __________________________________     Time: __________________________
For Accidental Injury
Nature of Injury:  ______________________________________________________________________________________
____________________________________________________________________________________________________
X-Ray Taken:                      Yes                      No                    Date taken: ____________________________________
Diagnosis and Treatment Given: __________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Describe any other disease or infirmity affecting present condition: ______________________________________________
For Sickness
Nature of Illness: ______________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Diagnosis and Treatment Given: __________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
When did patient's symptoms first appear: _________________________________________________________________
Describe any other disease or informity affecting present condition: _____________________________________________
____________________________________________________________________________________________________
Is condition due to Pregnancy:      Yes            No       Is illness due to any pre-existing condition:             Yes          No
If Hospitalised, please provide the following details:
Name of Hospital/ Clinic: ________________________________________________________________________________
Address: _____________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Attenting Doctor's Name: _______________________________________________________________________________
Date:
Signature:_________________________________________________
	Attending Doctor's Signature