Trip Cancellation Claim Form

Travel Insured International, Inc.

P.O. Box 6503, 855 Winding Brook Drive
Glastonbury, CT 06033-6503
Phone: 800-243-2440, fax: 860-430-2363
Email: [email protected], www.travelinsured.com

Section 1 - To Be Completed by the Planholder Who is Claiming Benefits

Name and Address of Planholder Date of Birth Plan/Policy #

MICHAEL MANDLER 09/28/1941 150409WTP14079

Home Phone # Alternate Phone #
46 CLAIMONT DR
WOODKLIF LAKE, NJ 07677 201-573-8960 201-650-7173
Trip Departure Date Trip Return Date
8/4/2015 9/1/2015
Planholder’s Email Initial Trip Deposit Date
[email protected] 4/9/2015 correction 1/14/2015
Name and Address of Travel Coordinator/Tour Operator Date Incident Occurred Date Trip Cancelled
08/03/2015
Coordinator’s Phone # Coordinator’s Fax #

Names of travel companion(s) Coordinator’s Email

Gail Mandler
Type of Claim Please briefly explain the circumstances of your claim:
Purchased airline tickets January 14th/2015 to travel to Poland and Israel. Late February of that year we fund out that My wife Gail has a
x Trip Cancellation lining of the uterus cancer. Following surgery she started Chemotherapy on April 8th and completed July 22nd. Her oncologist told us not to
cancel our trip since he believed that she will be fine to travel. After five treatments Gail was fine and recovered very quickly, however after the
Occupancy Upgrade 6th chemotherapy Gail was very week unable to function and slept only for few hours. Despite additional medications prescribed by her
Postponement of Departure oncologist her situation did not change that much. It was obvious that based on her condition she will not be able to travel and one day before

Date
departure we asked the travel agent to cancel the trip.

Do you have any other travel insurance that may provide coverage for this claim? Yes No If yes, please identify the name of
the travel insurance company:

Section 2 - Claimed Expenses

Enter the total of all claimed expenses in the table below. You will need to provide supporting documentation in order for
the claim to be processed. See the Trip Cancellation Required Documents Checklist for required documents.
Category Amount Definition
Airfare Expense $ 3,248.12 Value of unused airline tickets **

Land/Sea Expense $ Cost of land or cruise arrangements

Tour Expense $ Hotels or any other non-refundable trip costs

2,670.27
Total Expenses $ 5,918.39 Sum of all the above expenses

Refunds $ 0 Refunds received

Total Claim Amount $5,918.39 Total expenses minus refunds

** If you are claiming an amount for unused Airfare, do you plan on using the tickets within 1 year from the issue date? Yes No x
Section 3 - Declaration

Please proceed to page 2 of this form and read the appropriate fraud notice for your state of residence. After reading, please sign
and date the Claim Form Fraud Statement and send it to us with your claim submission.

NOTE: Submissions will not be considered complete without a signed Claim Form Fraud Statement.

SD-TCF (5/14), Page 1 of 2

T-12031
Trip Cancellation Claim Form

CLAIM FORM FRAUD STATEMENT

For residents of all states other than those listed below: Any person who knowingly presents a false or fraudulent claim for
payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
Arizona: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents
a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
Alaska and Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a statement
of claim containing any materially false, incomplete or misleading information or conceals, for the purpose of misleading, information
concerning any fact material thereto commits a fraudulent insurance act, which is a crime and may be prosecuted under state law.
California: For your protection California law requires the following to appear on this form: Any person who knowingly presents a false
or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the
purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil
damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or
information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard
to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department
of regulatory agencies.
Florida: WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or
an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Idaho: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement of claim containing
any false, incomplete, or misleading information is guilty of a felony.
Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly
or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in
prison.
New Hampshire: Any person who, with a purpose to injure, defraud, or deceive any insurance company, files a statement of claim
containing any false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud, as provided in
RSA 638:20.
New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal
and civil penalties.
New Mexico and Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files
an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading,
information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to
criminal and civil penalties.
Oklahoma: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of
an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Tennessee and Virginia: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for
the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
Texas: Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may
be subject to fines and confinement in state prison.
New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information
concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty
not to exceed five thousand dollars and the stated value of the claim for each such violation.

I have read the foregoing Claim Fraud Notice for my state of residence and the answers on this claim form are true and
complete according to the best of my knowledge and belief.

_____________________________________ __________________
Signature of Planholder Date

SD-TCF (5/14), Page 2 of 2

T-12031 150409WTP14079
 Attending Physician’s Statement
Travel Insured International; Claims Department
P.O. Box 6503, 855 Winding Brook Drive
Glastonbury, CT 06033-6503
Phone: 800-243-2440, Fax: 860-430-2363
Email: [email protected], www.travelinsured.com

Section 1 – Planholder Information

Name of Planholder Relationship to Patient Plan/Policy #
MICHAEL MANDLER 150409WTP14079

Section 2 – Patient Information (to be completed by Physician)

Patient Name (First, Middle, Last) Diagnosis and ICD-9 Code

What is the exact date that symptoms first appeared? When did the patient first consult you for this condition?

List all dates that you provided treatment for this condition:

Did you advise the trip be cancelled or interrupted due to the patient’s medical condition? Yes No If yes, please explain:

Has the patient ever had the same or similar condition? Yes No If yes, what was the date?

Is this condition a complication of an underlying condition? Yes No If yes, please list all dates you provided treatment for this
condition.

Was this patient referred to you by another physician? Yes No If yes, what was the date referred?

Name of Referring Physician Phone #

Was the patient hospitalized? Yes No If yes, please provide the name of the hospital.

Was this an emergency room admission? Yes No Date Admitted Date Discharged

Please note: All of the above requested information is necessary for the processing of the planholder’s claim. Any omitted
items will delay processing.

Section 3 – Physician Information (to be completed by Physician)

Physician’s Name Phone #

Specialty Fax #

Any person who knowingly and with intent to injure, defraud or deceive any insurance company, files a statement of claim containing
any false, incomplete, or misleading information may be guilty of a criminal act punishable by law.

I have read the forgoing and the Claim Form Fraud Statement on page 2 of this form and the above answers are true and complete
according to the best of my knowledge and belief.

____________________________________________ ______________
Signature of Physician Date

SD-APS (5/14), Page 1 of 2

T-12040
Attending Physician’s Statement

CLAIM FORM FRAUD STATEMENT

For residents of all states other than those listed below: Any person who knowingly presents a false or fraudulent claim for
payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may
be subject to fines and confinement in prison.
Arizona: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly
presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
Alaska and Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a
statement of claim containing any materially false, incomplete or misleading information or conceals, for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and may be
prosecuted under state law.
California: For your protection California law requires the following to appear on this form: Any person who knowingly presents
a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state
prison.
Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for
the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance
and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or
misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the
policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado
division of insurance within the department of regulatory agencies.
Florida: WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of
claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Idaho: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement of claim
containing any false, incomplete, or misleading information is guilty of a felony.
Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who
knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines
and confinement in prison.
New Hampshire: Any person who, with a purpose to injure, defraud, or deceive any insurance company, files a statement of
claim containing any false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud,
as provided in RSA 638:20.
New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to
criminal and civil penalties.
New Mexico and Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person
files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects
such person to criminal and civil penalties.
Oklahoma: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the
proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Tennessee and Virginia: It is a crime to knowingly provide false, incomplete or misleading information to an insurance
company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
Texas: Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime
and may be subject to fines and confinement in state prison.
New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading,
information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject
to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

SD-APS (5/14), Page 2 of 2

T-12040 150409WTP14079
Planholder/Patient Authorization Claim Form
Travel Insured International; Claims Department
P.O. Box 6503, 855 Winding Brook Drive
Glastonbury, CT 06033-6503
Phone: 800-243-2440, Fax: 860-430-2363
Email: [email protected], www.travelinsured.com

Section 1 – Planholder Information

Name and Address of Planholder Plan/Policy #
MICHAEL MANDLER 150409WTP14079
46 CLAIMONT DR Home Phone # Alternate Phone #

WOODKLIF LAKE, NJ 07677 201-573-8960

Trip Departure Date Trip Return Date
8/4/2015 9/1/2015
Section 2 – Patient Information
Patient’s Legal Name (First, Middle, Last) Date of Birth Was the patient scheduled to
Gail Mandler 02/25/1947 go on the trip? Yes x No
Provide the names, phone # and fax # for all physicians, hospitals and medical facilities that provided treatment for the illness or injury
that caused this claim: Memorial Sloan- Kettering
Name: Dr. David Spriggs Name: Name:
Phone #:646-888-4223 Phone #: Phone #:
Fax #: 646-888-4270 Fax #: Fax #:
Please list the names of any prescription medications presently taken:

Reason for Treatment: * If injury is a result of an accident please describe the accident:
x - Illness
- Injury *
Was a motor vehicle involved? Yes No x If yes, please list the names of the involved parties, insurance carriers and policy
numbers.

Was a police report filed? Yes No x If yes, please identify the Police Department where it was filed.

Section 3 – Authorization to obtain and disclose information in connection with a claim for benefits:
To all providers of medical or dental services or suppliers and their representatives:
For purposes of claims administration and audit, I authorize you to furnish Travel Insured International, Inc., (TII) or its representatives
performing business or legal functions, any information available about the medical history, condition and treatment of, including
information relating to mental illness and use of drugs and alcohol, to determine eligibility for benefit payments under the Plan/Policy
number identified above.
I authorize TII to use such information and to disclose it for the above purposes to its affiliates, underwriters and any agent acting
expressly on behalf of TII and to any person who has an authorization specifically permitting the disclosure. If there is potential
fraudulent activity such information may be disclosed to insurance support organizations, fraud information clearinghouses and to
governmental authorities as may be permitted or required by law.
I understand that any personal information or other information released in accordance with this Authorization may no longer be
protected by applicable federal and state privacy laws.
This authorization is valid for one year from the date below. I understand that I have a right to revoke this Authorization by providing
written notice to TII. However, this Authorization may not be revoked if TII or its representatives have taken action on this Authorization
prior to receiving my written notice. I further understand that this Authorization is voluntary and that my refusal to sign this Authorization
will not affect my treatment or eligibility for benefits. If I refuse to sign this Authorization, benefits may not be paid under the Plan/Policy
if additional health information is needed to determine my eligibility for benefits.
I agree that a facsimile of this Authorization shall be as valid as the original. I know that I have the right to ask for and receive a copy of
this authorization and to inspect the health information that I have authorized to be used or disclosed by this Authorization.

____________________________________________ ______________
Signature of Patient (Parent if patient is a minor) Date

SD-PPA (5/14), Page 1 of 1

T-12042
Trip Cancellation Claim
Required Documents Checklist

This Trip Cancellation Checklist can be used to submit claims related to:
• Cancellation of an entire trip.
• Occupancy Upgrade, sometimes known as Single Supplement Upgrade.
• Postponement of a departure date.
The sections below outline the forms and documentation that we will need to review your claim. The
information in Section 1 must be provided for all claims. Based on the reason for the claim, you may also need
to provide documentation from one of the other sections of the checklist.
Reason for Claim Provide Documentation from:
Illness or Injury, Death, Other Section 1
Occupancy Upgrade (Single Supplement) Sections 1 and 2
Postponement of Departure Date Sections 1 and 3

SECTION 1 – Information Needed for All Claims

1. Claim Form
Complete and sign Trip Cancellation Claim Form.
2. Proof of Loss
x Illness or Injury: Compete and sign the Planholder/Patient Authorization Claim Form and ask your
physician complete the Attending Physician’s Statement.
Death: Provide a photocopy of the Death Certificate.
Cancel for Work Reason: Provide a written statement from employer stating why work prevented
you or your traveling companion from taking the scheduled trip.
Other: Provide documentation for the reason that you cancelled your trip.
3. Proof of Payment (How did you pay for the planned trip?)
Check: Provide photocopies of the processed checks (front and back).
Cash: Provide photocopies of the cash receipts.
x Credit Card: Provide photocopies of the section of your monthly credit card statements showing all
payments made for your travel arrangements.
4. Airline Tickets
x Provide a photocopy of the ticket or a photocopy of the e-ticket receipt which includes ticket numbers
and dates of travel.
5. Other Itemized Invoices, Receipts, Tour Flyers and Brochures
Provide photocopies of all itemized payment invoices and purchase receipts.
Provide photocopies of your trip flyer or tour brochure outlining your trip that states the cancellation
policy.
6. Refunds (Did the airline, hotel, or cruise line give any money back when you cancelled?)
Yes. I have received a refund: Provide photocopies of the refund checks or credit card statements
showing the refunds that you received.
x No. I have not received a refund: Provide a letter from your travel agent or travel provider stating that
your travel arrangements are not refundable.

SD-TCC-WTP (5/14), Page 1 of 3

T-12030 150409WTP14079
Trip Cancellation Claim
Required Documents Checklist

SECTION 2 – Occupancy Upgrade (Single Supplement)

1. Proof of Loss (Why did your travel companion cancel?)
x Illness or Injury: Provide the Attending Physician’s Statement Claim Form and Patient Authorization
Claim Form.
Death: Provide a photocopy of Death Certificate.
Other: Provide the documentation for the reason your travel companion cancelled their trip.
2. Proof of Payment (How did you pay for the cost of the occupancy upgrade?)
Check: Provide photocopies of the processed checks.
Cash: Provide photocopies of the cash receipts.
x Credit Card: Provide photocopies of the monthly credit card statements showing all payments made
for your trip.
3. Trip Flyer or Tour Brochure
Provide a photocopy of the trip flyer or tour brochure listing the price for the Occupancy Upgrade.

Section 3 – Postponement of Departure Date

1. Proof of Loss (Why did you postpone your departure date?)
Illness or Injury: Provide the Attending Physician’s Statement Claim Form and Planholder/Patient
Authorization Claim Form.
Due to a Death: Provide a photocopy of Death Certificate.
Other: Provide the documentation verifying the reason your departure was postponed.

2. Proof of Payment (How did you pay for the change fees?)
Check: Provide photocopies of the processed checks (front and back).
Cash: Provide photocopies of the cash receipts.
Credit Card: Provide photocopies of the section of the monthly credit card statements showing all
payments made for your travel arrangements.

3. Itemized Invoices
Provide a photocopy of the invoice showing the amount of change fees.
4. Did You Miss Pre-Paid and Non-Refundable Parts of Your Trip?
If yes, please contact us by phone or email and we will send you a Travel Coordinator’s Statement
that will need to be completed by your travel coordinator.

SD-TCC-WTP (5/14), Page 2 of 3

T-12030 150409WTP14079
Trip Cancellation Claim
Required Documents Checklist

SECTION 4 –Submit Your Documentation

Please return completed forms and required documentation to:

Mail: Travel Insured International, Inc.

Attention: Claims Department
P.O. Box 6503, 855 Winding Brook Drive
Glastonbury, CT 06033-6503

Fax: 860-430-2363

Email: [email protected]

Please do not use staples, tape or paperclips. Please do not return this checklist.

If you have questions about the forms or required documentation, please call us or send us an email. Our
Claim representatives are available to assist you Monday through Friday from 8:00am to 5:30pm.

Phone: (800) 243-2440 (in the U.S. and Canada)

(860) 528-7663 (outside U.S.)

SD-TCC-WTP (5/14), Page 3 of 3 150409WTP14079

T-12030
 Medical Expense Claim
Required Documents Checklist

This Medical Claim Checklist can be used to submit claims related to medical costs incurred for the emergency
treatment of an illness or injury that first manifested itself on a covered trip.

The sections below outline the forms and documentation that we will need to review your claim. The
information requested must be provided for all claims.

Primary versus Excess Medical Coverage (Who do I file the claim with first?)

If your travel policy has excess medical coverage, you must file your claim with your primary health insurance
company first. If your primary insurer does not pay the entire amount of the claim, follow the instructions in the
checklist below and mail the forms and required documentation to Travel Insured at that time.

If your travel policy has primary medical coverage, follow the instructions in the checklist below and mail the
forms and required documentation to Travel Insured.

SECTION 1 - Information Needed for All Claims

1. Claim Forms
Complete and sign the Medical Expense Claim Form.
Complete and sign the Planholder/Patient Authorization Claim Form.
2. Proof of Loss (Why did you seek medical care on your trip?)
Provide photocopies of any documents listing the diagnosis and explaining the nature of your
sickness or injury.
3. Medical Expense Receipts
Provide photocopies of all invoices and receipts showing the payments that you made for your
medical expenses.
4. Proof of Payment (How did you pay?)
Medical Expenses
Initial Trip Deposit
For each of the two listed items above, we will need the applicable of the following as proof of payment:
• Check: Provide photocopies of the processed checks (front and back)
• Cash: Provide photocopies of the cash receipts.
• Credit Card: Provide photocopies of the section of the monthly credit card statements showing all
payments made for your travel arrangements.
5. Verification of Travel Arrangements: Tour Flyers and Brochures
Provide photocopies of your trip flyer or tour brochure outlining your trip itinerary.
6. Other Insurance Coverage (Did you file this claim with another insurer?)
If yes, provide photocopies of the Explanation of Benefits showing the amount of the reimbursement.

SD-MEC (5/14), Page 1 of 2 150409WTP14079

T-12036
 Medical Expense Claim
Required Documents Checklist

SECTION 2 –Submit Your Documentation

Please return completed forms and required documentation by mail to:

Mail: Travel Insured International, Inc.

Attention: Claims Department
P.O. Box 6503, 855 Winding Brook Drive
Glastonbury, CT 06033-6503

Fax: 860-430-2363

Email: [email protected]

Please do not use staples, tape or paperclips. Please do not return this checklist.

If you have questions about the forms or required documentation, please call us or send us an email. Our
Claim representatives are available to assist you Monday through Friday from 8:00am to 5:30pm.

Phone: (800) 243-2440 (in the U.S. and Canada)

(860) 528-7663 (outside U.S.)

SD-MEC (5/14), Page 2 of 2

T-12036 150409WTP14079
Medical Expense Claim Form
Travel Insured International, Inc.
P.O. Box 6503, 855 Winding Brook Drive
Glastonbury, CT 06033-6503
Phone: 800-243-2440, Fax: 860-430-2363
Email: [email protected], www.travelinsured.com

Section 1 - To Be Completed by the Planholder Who Is Claiming Benefits

Name and Address of Planholder Plan/Policy #
MICHAEL MANDLER 150409WTP14079
46 CLAIMONT DR Home Phone # Alternate Phone #
WOODKLIF LAKE, NJ 07677
Planholder’s Email

Trip Departure Date Trip Return Date Initial Trip Deposit Date Date Incident Occurred
8/4/2015 9/1/2015 4/9/2015
Name and Address of Travel Coordinator Coordinator’s Phone # Coordinator’s Fax #

Coordinator’s Email

Name of travel companion(s)

Do you have any other travel insurance that may provide coverage for this claim? Yes  No . If yes, please identify the name
of the travel insurance company:

Do you have other medical insurance? Yes  No  Have you submitted a claim to your primary or supplemental insurance
carrier? Yes  No 
Primary Insurance Carrier Policy # Phone #

Supplemental Insurance Carrier Policy # Phone #

Section 2 – Amount Being Claimed

Please list all medical expenses incurred as a result of this sickness or injury. Enclose copies of medical bills, reports and
explanations of benefits from your Primary and Supplemental insurance.
Amount paid by
Name of Provider Date Incurred Amount of Bill Amount Claimed
Other Insurance

$ _____________ Total amount paid for all medical treatment received while on trip. (Enclose all invoices)

$ _____________ Total amount payable from sources other than Travel Insured. (Enclose all responses you received)

$ _____________ Total amount being claimed from Travel Insured International, Inc.

SD-MEF (5/14), Page 1 of 3

T-12037
Medical Expense Claim Form

Section 3 – Patient Information

Patient Legal Name Date of Birth Gender:
Male  Female 
Date symptoms first appeared Are you a U.S. Citizen? Yes  No 

Give name of sickness or injury (diagnosis):

Fully describe how and where sickness/injury occurred:

Was there previous treatment for these conditions prior to the purchase of our plan? Yes  No  If yes, when?

Name and address of physician who first treated the Physician’s Phone # Physician’s Fax #
condition.

Physician’s Specialty:

Name and address of other physician(s) who treated the Physician’s Phone # Physician’s Fax #
condition.

Physician’s Specialty:

Name and address of hospital (if hospitalized) Hospital Phone # Date Admitted

Date Discharged

What country are the medical bills from?

Was an accident report filed for this incident? Yes  No  If yes, please provide a copy.

Section 4 – Declaration

Please proceed to page 3 of this form and read the appropriate fraud notice for your state of residence. After reading, please sign and
date the Claim Form Fraud Statement and send it to us with your claim submission.

NOTE: Submissions will not be considered complete without a signed Claim Form Fraud Statement.

SD-MEF (5/14), Page 2 of 3

T-12037 150409WTP14079
Medical Expense Claim Form

CLAIM FORM FRAUD STATEMENT

For residents of all states other than those listed below: Any person who knowingly presents a false or fraudulent claim for
payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
Arizona: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents
a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
Alaska and Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a statement
of claim containing any materially false, incomplete or misleading information or conceals, for the purpose of misleading, information
concerning any fact material thereto commits a fraudulent insurance act, which is a crime and may be prosecuted under state law.
California: For your protection California law requires the following to appear on this form: Any person who knowingly presents a false
or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the
purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil
damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or
information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard
to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department
of regulatory agencies.
Florida: WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or
an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
Idaho: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement of claim containing
any false, incomplete, or misleading information is guilty of a felony.
Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly
or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in
prison.
New Hampshire: Any person who, with a purpose to injure, defraud, or deceive any insurance company, files a statement of claim
containing any false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud, as provided in
RSA 638:20.
New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal
and civil penalties.
New Mexico and Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files
an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading,
information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to
criminal and civil penalties.
Oklahoma: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of
an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Tennessee and Virginia: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for
the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
Texas: Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may
be subject to fines and confinement in state prison.
New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information
concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty
not to exceed five thousand dollars and the stated value of the claim for each such violation.

I have read the foregoing Claim Fraud Notice for my state of residence and the answers on this claim form are true and
complete according to the best of my knowledge and belief.

_____________________________________ __________________
Signature of Planholder Date

SD-MEF (5/14), Page 3 of 3

T-12037 150409WTP14079
Planholder/Patient Authorization Claim Form
Travel Insured International; Claims Department
P.O. Box 6503, 855 Winding Brook Drive
Glastonbury, CT 06033-6503
Phone: 800-243-2440, Fax: 860-430-2363
Email: [email protected], www.travelinsured.com

Section 1 – Planholder Information

Name and Address of Planholder Plan/Policy #
MICHAEL MANDLER 150409WTP14079
46 CLAIMONT DR Home Phone # Alternate Phone #
WOODKLIF LAKE, NJ 07677
Trip Departure Date Trip Return Date
8/4/2015 9/1/2015
Section 2 – Patient Information
Patient’s Legal Name (First, Middle, Last) Date of Birth Was the patient scheduled to
go on the trip? Yes No
Provide the names, phone # and fax # for all physicians, hospitals and medical facilities that provided treatment for the illness or injury
that caused this claim:
Name: Name: Name:
Phone #: Phone #: Phone #:
Fax #: Fax #: Fax #:
Please list the names of any prescription medications presently taken:

Reason for Treatment: * If injury is a result of an accident please describe the accident:
- Illness
- Injury *
Was a motor vehicle involved? Yes No If yes, please list the names of the involved parties, insurance carriers and policy
numbers.

Was a police report filed? Yes No If yes, please identify the Police Department where it was filed.

Section 3 – Authorization to obtain and disclose information in connection with a claim for benefits:
To all providers of medical or dental services or suppliers and their representatives:
For purposes of claims administration and audit, I authorize you to furnish Travel Insured International, Inc., (TII) or its representatives
performing business or legal functions, any information available about the medical history, condition and treatment of, including
information relating to mental illness and use of drugs and alcohol, to determine eligibility for benefit payments under the Plan/Policy
number identified above.
I authorize TII to use such information and to disclose it for the above purposes to its affiliates, underwriters and any agent acting
expressly on behalf of TII and to any person who has an authorization specifically permitting the disclosure. If there is potential
fraudulent activity such information may be disclosed to insurance support organizations, fraud information clearinghouses and to
governmental authorities as may be permitted or required by law.
I understand that any personal information or other information released in accordance with this Authorization may no longer be
protected by applicable federal and state privacy laws.
This authorization is valid for one year from the date below. I understand that I have a right to revoke this Authorization by providing
written notice to TII. However, this Authorization may not be revoked if TII or its representatives have taken action on this Authorization
prior to receiving my written notice. I further understand that this Authorization is voluntary and that my refusal to sign this Authorization
will not affect my treatment or eligibility for benefits. If I refuse to sign this Authorization, benefits may not be paid under the Plan/Policy
if additional health information is needed to determine my eligibility for benefits.
I agree that a facsimile of this Authorization shall be as valid as the original. I know that I have the right to ask for and receive a copy of
this authorization and to inspect the health information that I have authorized to be used or disclosed by this Authorization.

____________________________________________ ______________
Signature of Patient (Parent if patient is a minor) Date

SD-PPA (5/14), Page 1 of 1

T-12044