The New India Assurance Company Limited
87, M. G. Road, Fort, Mumbai, India – 400 001

CLAIM FORM FOR (CITIBANK) TRAVEL PACKAGE INSURANCE POLICY

(To be submitted to below mentioned address for lodging claim)

CORIS INTERNATIONAL

8 RUE AUBER, 75009, PARIS, FRANCE

Name of Person Claiming : Mr. / Mrs.

Home Address in India :

 

 

Occupation:                                                                                    Day : __________ Time : ____________ Tel No. : _________________

DETAILS OF POLICY                  C.O. Code                   Office Code                      Plan           Category                          Serial No  

 Policy Number  
     
 
           
 
 
 
     
 
           

Date – Policy Issued:

Date – Trip Commenced :

No. of Days :

Scheduled Date of Return:

Geographical Limits                                                            Worldwide Excl.                                     Worldwide Incl.
                                                                                              USA / CANADA                                    USA / CANADA

NAME AND AGE OF EACH PERSON INCLUDED IN THE CLAIM

Mr. / Mrs. / Miss.                                                                  Initials                                                             Surname                                                      

Date of Birth                                 ____ / ____ / ______
                                                            DD   MM      YY

POLICY SECTION RELATING TO CLAIM (Tick Boxes)

Medical Expenses   
Personal Accident  
Loss of Checked in Baggage  
Delay of Checked in Baggage  
Loss of Passport  
Personal Liability  

DATE OF CLAIM OCCURANCE:                                                   TRIP DESTINATION:

PLEASE COMPLETE APPROPRIATE SECTION OF CLAIM FORM AND READ CAREFULLY THE INSTRUCTIONS RELATING TO SUPPORTING DOCUMENTS REQUIRED. WHEN COMPLETED PLEASE SIGN DECLARATION :

I Declare that to the best of my knowledge all particulars contained in this form are true. I also authorize Coris to obtain my medical records or information necessary to process the claim.

 

Signed:                                                                                                                    Date:                                                Place: