Claimant Questionnaire

(Also known as Claimant Statement and Authorization Form)

NOTICE TO INSURED PERSONS: Your insurance requires submission of valid Proof of Claim* within 180 days of the date the service is provided or supply purchased. The following questions about your travel incident are an essential part of Proof of Claim. Failure to submit an accurate, completed and signed Claimant Questionnaire together with all required attachments within the specified time frame will result in processing delays and may result in denial of coverage for failure to submit Proof of Claim.

*Proof of Claim consists of this Claimant Questionnaire, completed, signed and including all required attachments. Required attachments may include itemized bills/receipts, copies of visas, passports, other travel documents, and/or medical records.

Step 1 of 6

Company

This field is for validation purposes and should be left unchanged.

PART A: CLAIMANT INFORMATION

Claimant (Member) Name(Required)

First Last

ID Number(Required)

(found on ID card)

Gender(Required)

Date of Birth(Required)

Email(Required)

Phone(Required)

Home Country Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Is your current address the same as your home country address?(Required)

Yes

No

Current Address(Required)

Street Address City State / Province / Region ZIP / Postal Code Country

Country of Citizenship(Required)

Select one

Passport/Visa Number(Required)

Please upload a copy of the FACE page of your passport.(Required)

Drop files here or

Accepted file types: jpg, jpeg, png, webp, pdf, docx, doc, xls, xlsx, Max. file size: 2 MB, Max. files: 1.

Primary Country Visited During Trip(Required)

Select one

Did you visit another country?

Yes

No

2nd Country Visited

Select one

Did you visit another country?

Yes

No

3rd Country Visited

Select one

Do you have any other coverage (medical, indemnity, liability or other)?(Required)

Yes

No

Please provide details of this other coverage:(Required)

Insurance Company

Policy Number

Name of Policy Holder

Insurance Phone Number

Insurance Company Address

PART B: CLAIM DETAILS

Tell us about your travel incident (accident/injury or illness).

1. Travel Incident Name

A short sentence or phrase summarizing your incident, i.e. "Stomach Flu" or "Car Accident Broken Leg" etc

2A. Incident Date(Required)

What day did you first have symptoms of this accident/injury or illness?

2B. Incident Time(Required)

Around what time did the symptoms begin (best estimate)

:

3A. Incident Location(Required)

Where were you located when this incident began?

3B. Incident Address

Please enter address if known

4A. Incident Description(Required)

Describe your accident/illness or injury in full detail from the beginning, including all symptoms.

4B. Upload relevant documents as needed here:

example: a clinic visit summary

Drop files here or

Accepted file types: jpg, jpeg, png, webp, pdf, docx, doc, xls, xlsx, Max. file size: 2 MB.

5. Have you had the same or a similar condition in the past 5 years?(Required)

Yes

No

5A. Please provide additional details:(Required)

6. Prior to the onset of your current condition, were you taking any prescription medications?(Required)

Yes

No

6A. List all your prescriptions below:

Prescription Name

Dosage

What does it treat?

CLICK THE + BUTTON TO LIST ADDITIONAL ENTRIES

6B. Or upload a list of your prescriptions:

Drop files here or

Accepted file types: jpg, jpeg, png, webp, pdf, docx, doc, xls, xlsx, Max. file size: 2 MB, Max. files: 1.

7. Do you have a primary care doctor?(Required)

Yes

No

7A. Doctor's Name(Required)

7B. Doctor's Phone

7C. Doctor's Address

PART C: TREATMENT RECEIVED OUTSIDE THE U.S.

Location Name(Required)

(Where did you receive treatment?)

Location Address

(if known)

Select Foreign Currency Used for Treatment(Required)

Please list foreign currency used for treatment:(Required)

Date

List(Required)

Name of Provider

Type of Service/Name of Drug Provided:

Amount Charged:

Date

List

Name of Provider

Type of Service/Name of Drug Provided:

Amount Charged:

Date

List

Name of Provider

Type of Service/Name of Drug Provided:

Amount Charged:

Date

List

Name of Provider

Type of Service/Name of Drug Provided:

Amount Charged:

Date

List

Name of Provider

Type of Service/Name of Drug Provided:

Amount Charged:

Date

List

Name of Provider

Type of Service/Name of Drug Provided:

Amount Charged:

Upload bills, invoices or paid receipts:(Required)

Drop files here or

Accepted file types: jpg, jpeg, png, webp, pdf, docx, doc, xls, xlsx, Max. file size: 2 MB.

Are you seeking reimbursement for services paid out-of-pocket INSIDE THE UNITED STATES?

Yes

No

PART C. TREATMENT RECEIVED INSIDE THE U.S.

Location Name(Required)

(Where did you receive treatment?)

Location Address

(if known)

Date

List

Name of Provider

Type of Service/Name of Drug Provided:

Amount Charged:

Date

List

Name of Provider

Type of Service/Name of Drug Provided:

Amount Charged:

Date

List

Name of Provider

Type of Service/Name of Drug Provided:

Amount Charged:

Date

List

Name of Provider

Type of Service/Name of Drug Provided:

Amount Charged:

Date

List

Name of Provider

Type of Service/Name of Drug Provided:

Amount Charged:

Date

List

Name of Provider

Type of Service/Name of Drug Provided:

Amount Charged:

Upload bills, invoices or paid receipts:(Required)

Drop files here or

Accepted file types: jpg, jpeg, png, webp, pdf, docx, doc, xls, xlsx, Max. file size: 2 MB.

PART D: VERIFICATION

Signature(Required)

Please indicate your relationship to the claimant:(Required)

Date Signed(Required)

CAPTCHA

If you need to follow up with Point Comfort directly:

Phone Calls from Within the U.S.

833-483-0001

Collect International Calls:

+1 (317) 210-2010

Email:

travelclaims@pointcomfort.com

Please complete the below questionnaire for each new injury or illness for which claims will be submitted (either by you or by your provider).