Travel Claim Form — Cancellation, Curtailment, Alteration

Travel destination

Scheduled trip dates

Travel order number (if applicable)

Reason for travel Business trip Leisure Long term secondment

Country where accident occurred

Full name

Position

Telephone number

Email address

Is this claim payable direct to the company?

YES NO

The claimant should complete and sign this form. If the claimant is under 18 years of age, this form should be completed by one of their

parents or legal guardians. If the claimant is unable to complete this form, the person completing and signing this form should give their

details in the Declaration on page 4.

Travel Claim Form — Cancellation, Curtailment, Alteration, Disruption or Delay

Lifeline Plus Group Personal Accident and Travel Insurance

If you claim as a company representative (HR, Finance, etc.) please provide your details:

Full name

Address

Postcode

Telephone number

Email address

Occupation

Relationship to policyholder Employee Spouse of employee Visitor

Contractor Child of employee Other (please state)

If the claimant is a spouse or child of an employee, please

provide the name of the employee

Country

Date of birth

Details of the claimant (person who had to cancel, curtail, alter, disrupt or delay their trip):

DD / MM / YYYY

DD / MM / YYYY DD / MM / YYYY

Policy number

Name of company

Address

Postcode

Does the claimant work at this address?

If not where does the claimant work? Please name branch/subsidiary and location

Country

Details of the policyholder (insured company):

YES NO

Details of the trip:

Date of delay

Departure details: Original date and time New date and time

Reason for delay

Departing airport, station or port (or transit airport,

station or port if delay occurred in transit)

Flight/Train/Ship number

Flight/Train/Ship operator

Total time delayed at airport, port or station (days, hours)

Date and time illness or injury was contracted

Place of illness or injury

Nature of illness or injury

How was the injury

sustained or the illness

contracted?

Have you had the same illness/condition before?

If Yes, provide dates

Address and contact details of qualiﬁed medical professional who conﬁrmed you cannot travel or have to alter travel plans

Was the Assistance Company contacted?

If Yes, give details and reference number

Does another company insure the expenses you’re claiming?

If Yes, give details

YES

Reason for curtailment or alteration of the trip (e.g. strike, weather,

employee resigned, illness) (if illness, please also ﬁll in section D)

Date returned home Total cost of trip

Date Travel Agent/Tour Operator/Airline notiﬁed of curtailment or alteration (if applicable)

What refund, if any, has been made or to be made to you by your Travel Agent/ Tour Operator/ Airline?

What is the amount of your claim?

Reason for cancellation (e.g. strike,

weather, employee resigned, illness)

(if illness, please also ﬁll in section D)

Total cost of trip

Date Travel Agent/Tour Operator/Airline notiﬁed of cancellation (if applicable)

What refund, if any, has been made or to be made to you by your Travel Agent/ Tour Operator/ Airline?

What is the amount of your claim?

DD / MM / YYYY

A. Details of cancellation (if applicable):

B. Details of curtailment or alteration (if applicable):

C. Details of travel delay (if applicable):

Please complete the sections which apply.

D. Details of illness or injury which prevented you from travelling or caused travel alteration (if applicable):

If bank transfer:

Name of account holder Account number

Name of bank

Address of bank

Sort code (UK only)

For international transfers only (outside UK):

International bank account number (IBAN)

SWIFT/IBC Code Account currency

Do you require a bank transfer? Do you require a cheque?

If cheque, make payment to

YES YESNO NO

How we use personal information:

AIG Europe Limited is committed to protecting the privacy of customers, claimants and other business contacts.

“Personal Information” identiﬁes and relates to you or other individuals (e.g. your partner or other members of your family). If you provide

Personal Information about another individual, you must (unless we agree otherwise) inform the individual about the content of this notice

and our Privacy Policy and obtain their permission (where possible) for sharing of their Personal Information with us.

The types of Personal Information we may collect and why – Depending on our relationship with you, Personal Information collected may

include: contact information, ﬁnancial information and account details, credit reference and scoring information, sensitive information about

health or medical conditions (collected with your consent where required by applicable law) as well as other Personal Information provided

by you or that we obtain in connection with our relationship with you. Personal Information may be used for the following purposes:

• Insurance administration, e.g. communications, claims processing and payment

• Make assessments and decisions about the provision and terms of insurance and settlement of claims

• Assistance and advice on medical and travel matters

• Management of our business operations and IT infrastructure

• Prevention, detection and investigation of crime, e.g. fraud and money laundering

• Establishment and defence of legal rights

• Legal and regulatory compliance (including compliance with laws and regulations outside your country of residence)

• Monitoring and recording of telephone calls for quality, training and security purposes

• Marketing, market research and analysis

Sharing of Personal Information — For the above purposes Personal Information may be shared with our group companies and third

parties (such as brokers and other insurance distribution parties, insurers and reinsurers, credit reference agencies, healthcare professionals

and other service providers). Personal Information will be shared with other third parties (including government authorities) if required by

laws or regulations. Personal Information (including details of injuries) may be recorded on claims registers shared with other insurers. We

are required to register all third party claims for compensation relating to bodily injury to workers’ compensation boards. We may search

these registers to prevent, detect and investigate fraud or to validate your claims history or that of any other person or property likely to be

involved in the policy or claim. Personal Information may be shared with prospective purchasers and purchasers, and transferred upon a

sale of our company or transfer of business assets.

International transfer — Due to the global nature of our business, Personal Information may be transferred to parties located in other

countries (including the United States, China, Mexico Malaysia, Philippines, Bermuda and other countries which may have a data protection

regime which is different to that in your country of residence). When making these transfers, we will take steps to ensure that your Personal

Information is adequately protected and transferred in accordance with the requirements of data protection law. Further information about

international transfers is set out in our Privacy Policy (see below).

Security of Personal Information — AAppropriate technical and physical security measures are used to keep your Personal Information

safe and secure. When we provide Personal Information to a third party (including our service providers) or engage a third party to collect

Personal Information on our behalf, the third party will be selected carefully and required to use appropriate security measures.

Your rights — You have a number of rights under data protection law in connection with our use of Personal Information. These rights may

only apply in certain circumstances and are subject to certain exemptions. These rights may include a right to access Personal Information,

a right to correct inaccurate data, a right to erase data or suspend our use of data. These rights may also include a right to transfer your

data to another organisation, a right to object to our use of your Personal Information, a right to request that certain automated decisions

Please complete if a payment may be due:

Signature

Date

DD / MM / YYYY

Declaration:

I declare that the whole of the statements made and any other supplementary statements forming part of this claim are true in every respect

and understand that a false declaration may invalidate my claim and could result in prosecution.

Full name

Telephone number

Email address

Relationship to claimant

Reason for completing the

form on behalf of the claimant

Details of the person completing the form (if not the claimant):

we make have human involvement, a right to withdraw consent and a right to complain to the data protection regulator. Further information

about your rights and how you may exercise them is set out in full in our Privacy Policy (see below).

Privacy Policy — More details about your rights and how we collect, use and disclose your Personal Information can be found in our full

Privacy Policy at: https://www.aig.co.uk/privacy-policy or you may request a copy by writing to: Data Protection Ofﬁcer, AIG Europe

Limited, The AIG Building, 58 Fenchurch Street, London EC3M 4AB.or by email at: dataprotectionofﬁcer[email protected].

Please include the following documents:

• Original travel arrangements documentation (ﬂights, accommodation, pre-paid excursions, car hire, etc)

• Medical certiﬁcate issued by GP or Consultant who conﬁrmed inability to travel or to continue to travel

• Unused portion of travel arrangements (accommodation, ﬂights, pre-paid excursions) in case of curtailment or alteration of travel plans

• Letter from carrier or airport authority conﬁrming the scheduled time and date of departure, the actual time of departure and the reason

for the delay (if you are claiming a travel delay beneﬁt)

• Receipts for essential purchases made

THE ISSUE OF THIS FORM DOES NOT CONSTITUTE AN ADMISSION OF LIABILITY UNDER THE POLICY.

To help us process your claim quickly, please make sure all sections are completed in full and all requested documents are scanned and

emailed or posted to us.

[email protected]

A&H Claims, American International Group UK Limited, The AIG Building,

2-8 Altyre Road, Croydon, Surrey CR9 2LG, United Kingdom

Telephone: +44 345 602 9429

Fax: +44 20 8253 7569

AT-10914-18 R06/20

Products and services are written or provided by subsidiaries or afﬁliates of American International Group, Inc. In the UK, the principal insurance provider is American

International Group UK Limited. This material is for information purposes. Not all products and services are available in every jurisdiction, and insurance coverage is governed

by the actual terms and conditions of insurance set out in the policy or in the insurance contract. Certain products and services may be provided by independent third parties.

Insurance products may be distributed through afﬁliated or unafﬁliated entities. For additional information, please visit our website at www.aig.com.

American International Group UK Limited is registered in England: company number 10737370. Registered address: The AIG Building, 58 Fenchurch Street, London EC3M

4AB. American International Group UK Limited is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and Prudential Regulation

Authority (FRN number 781109). This information can be checked by visiting the FS Register (www.fca.org.uk/register).

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