Claims notification - Travel PA

Travel Claim Notification

Submit your travel claim information online

At FPG Insurance, we’ve made it very easy for you to submit your travel claim online. Simply complete the following form and attach the relevant documents. We will then review your claim and if needed, a travel claim representative will contact you directly to confirm your claim details and request any additional information.

Basic Documents for Travel PA Claim

Police Report/Investigation Report
Original copy of Death Certificate
Proof of beneficiary's identity like Birth Certificate, Marriage Contract (Original)
Medical Certificate
Written proof of loss or damage verified by a written statement from police of transport provider. (Baggage loss)
Written proof of delay from transport provider together with receipt for the extra cost incurred. (Flight/Travel Delay)
Copy of credit card application and sales slip showing proof of his travel ticket.

Need help with your claim? Call us at +632 622 8611 or +632 859 1226 or email to hllander@fpgins.com or mdelacfuz@fpgins.com

Insured Information

Policyholder / Company Name ^*

Policy Number ^*

Claimant's Name ^*

Age ^*

Gender ^*

Male

Female

Home Landline

+62

Office Phone

+62

Mobile ^*

+62

Fax

+62

Email ^*

Address ^*

City ^*

Province ^*

Country

Zip

Type of Policy

International Travel

Domestic Travel

Type of Loss

Description of Loss

Brief Circumstances of loss

Date

Time

Is the Incident reported to the Police?

Yes

Details of Injury or Sickness

Nature and condition of injury or sickness

Place/Address where injury or sickness occurred

Hospitalization/Consultation dates

Attending Physician

Hospital Address

Telephone Number

+62

Fax

+62

Information on prior treatment of the same illness

Official Receipts Submitted

Official Receipt Number

Description

Amount

Upload Receipt Select Upload

Name of Payee as it should appear on the check

Total Amount Claimed

Upload Documents

Police Report/Investigation Report Select Upload

Original copy of Death Certificate Select Upload

Proof of beneficiary's identity like Birth Certificate, Marriage Contract (Original) Select Upload

Medical Certificate Select Upload

Written proof of loss or damage verified by a written statement from police of transport provider. (Baggage loss) Select Upload

Written proof of delay from transport provider together with receipt for the extra cost incurred. (Flight/Travel Delay) Select Upload

Copy of credit card application and sales slip showing proof of his travel ticket. Select Upload

Authority, Release and Declaration Statement

AUTHORITY: I hereby authorize my travel insurance and/or FPG Insurance Co., Inc. and its authorized representatives to request and receive any information, document or record from any hospital, clinic, laboratory, attending physician and other health service provider, which information or document relates to any examination laboratory test results , medical history and/or treatment in connection with this claim and such other matters related thereto.
RELEASE & SUBROGATION: Payment received by me in relation to this claim shall constitute as full, final and complete settlement. I further agree that the Company is subrogated to my rights of recovery on all claims and rights of action to the extent of the payments made and/or on account of the losses incurred with this claim and I further agree to authorize the Company to commence all legal actions and proceedings necessary to enforce my claim or recovery thereof with any undertaking to extend my cooperation or assistance whenever necessary.
DECLARATION: I declare that all data/statements found therein and on all pages of this form are complete and true , whether written by me of by anyone else on my behalf, shall be binding on me, and that the amounts being claimed herein are lawfully due to me under the terms and conditions of the policy.

I agree to the Authority, Release and Declaration Statement.

Submit

Travel Claim Notification

Submit your travel claim information online

Insured Information

Type of Policy

Type of Loss

Description of Loss

Details of Injury or Sickness

Official Receipts Submitted

Upload Documents

Authority, Release and Declaration Statement

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Travel Claim Notification

Submit your travel claim information online

Insured Information

Type of Policy

Type of Loss

Description of Loss

Details of Injury or Sickness

Official Receipts Submitted

Upload Documents

Authority, Release and Declaration Statement

CORPORATE PRODUCTS

CLAIMS

ABOUT US

CONNECT WITH US