Travel Claim Form


IMPORTANT - Please read before completing this form.

Many of the fraudulent claims we receive are made as Travel claims.

This usually has the result of increasing premiums and raising excesses. Rather than penalising you our honest and loyal clients whose support we value we’d prefer to ask your help in filling out this form.

Particularly we would point out that where items within a claim are proven to be inflated, the total claim will be declined.

We will be carefully monitoring all claim information with the aim of paying genuine claims quickly, stopping expensive fraudulent claims and keeping your premiums down.

Thank you for your co-operation.
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1    Personal Details
Customer Reference
Title
Insured's Full Name(s) 
Date(s) of Birth    
Email Address 
Telephone Number 
Day
Night
Postal Address 
Postcode 
 
Interested Party
(Bank, Finance Company etc)
Postal Address
Postcode
 
 
2    What Happened?
Where did the accident/loss/illness happen?
Country
Date it happened
What happened? (give full and precise details)
Was another party responsible? Yes No
If YES, who? Name
Address
Phone
In the last five years have you:
Had any insurance cancelled or refused? Yes No
Been charged with or convicted of any criminal offence (other than parking)? Yes No
If YES, give full details
 
 
3    Baggage Claim
Are you the sole owner of the property? Yes No
If the loss was theft or burglary were the Police advised? Yes No
If YES, where and when?
Have you made a claim against any airline or carrier responsible for your loss? Yes No
If YES, who?
 
 
4    Medical Expenses (ie cost incurred for any illness or injury)
Please list all expenses claimed for in the grid below
Was this a pre-existing condition (ie an illness you have had before) or for which you are taking medication? Yes No
If YES, where and when were you last treated by a doctor for this?
Please advise the name and address of your regular doctor
Australian Medicare
If your accident/illness happened in Australia, did you register for Medicare? Yes No
To be signed for all Medical Expenses Claims
The Company at its discretion, may obtain a Medical Certificate from a duly qualified medical practitioner in order to substantiate any claim made. I hereby authorise TOWER Insurance to obtain such medical report at the Company's expense. Yes No
If NO, please give details
 
 
5    List Baggage Property Claimed
Full description of Property lost, damaged or destroyed (including Serial No. and/or identifying marks) How old was the item? From whom purchased or acquired? (Name and Address) Present Purchase Price Repair Cost Depreciation Amount Claimed
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WARNING: Wilful or reckless exaggeration or inflation of the amount claimed will forfeit the claim and may result in prosecution.
 
 
6    Other Expenses or Medical Expenses Claimed
Account Received from Date Account Incurred Amount and Currency Claim Amount Paid Yes or No
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7    Declaration
Where any declaration is answered NO then further details will need to be provided below in the box headed 'Exceptions to this Declaration'.
I/We declare that:
All the statements in this claim form and any additional schedules are correct.  Yes No
The property and/or expenses claimed are correctly described in this form and were incurred, lost, stolen or damaged under the circumstances described overleaf.  Yes No
I/We have told TOWER Insurance everything relevant to this claim.  Yes No
I/We understand that:
Wilful or reckless exaggeration or inflation of the amount claimed will forfeit the claim and may result in prosecution.
The personal information provided in this claim form is being collected by TOWER Insurance to enable it to evaluate my/our claim.
I/We have certain rights of access to and correction of the personal information provided by me/us on this claim form or in support of this claim, but if I/we do provide incorrect information, TOWER Insurance may be entitled to decline the claim whether or not it is later corrected.
If any of the property in this claim for which I/we have received payment is subsequently recovered I/we will notify TOWER Insurance immediately and return the property to TOWER Insurance or will refund to TOWER Insurance the value of the recovered items.
I/We authorise TOWER Insurance to obtain personal information about me/us from any other party.
I/We authorise TOWER Insurance to obtain if required a copy of the police report from the Police relating to this claim.
Exceptions to this Declaration: