FPG Insurance

Insured Information

POLICYHOLDER / COMPANY NAME *

POLICY NUMBER *

CLAIMANT'S NAME *

AGE *

GENDER *

MALE

FEMALE

HOME LANDLINE

OFFICE PHONE

MOBILE

FAX

EMAIL *

ADDRESS *

CITY *

PROVINCE *

COUNTRY

ZIP CODE

Type of Policy

INTERNATIONAL TRAVEL

DOMESTIC TRAVEL

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

FAX

INFORMATION ON PRIOR TREATMENT OF THE SAME ILLNESS

Official Receipts Submitted

OFFICIAL RECEIPT NUMBER

DESCRIPTION

AMOUNT

UPLOAD RECEIPT

NAME OF PAYEE AS IT SHOULD APPEAR ON THE CHECK

TOTAL AMOUNT CLAIMED

Upload Documents

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.

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.

I have read and understood and voluntarily agreed to the collection, use, and disclosure of my personal data in accordance with FPG Privacy Policy.