Tangiers International | Insurance Claim Form

Policy Name
Date Policy Issued
Policy Number
Policy Start Date
Master Policy Number
Policy End Date
Name*
First Last
Email*
Contact Telephone Number*
Alternative Contact Telephone
Sex*
- Male
- Female
Date of Birth*
Country of Residence*
Home Address*
Street Address City ZIP / Postal Code Country
Current Address (if different from home address)
Street Address City ZIP / Postal Code Country
Passport/ID number*
Country of issue*
Occupation*
Date of occurence*
Country of incident*
City*
Please confirm the type of claim
- Medical Expense Claim
- Baggage Delay Claim
- Baggage Damage/Loss Claim
- Personal Property/Loss of Money
- Trip Cancellation Claim

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BANK DETAILS
In order to provide a fast and efficient service, we would like to pay your claim settlement directly into your bank account.

Please provide your bank details as requested below.
Your Details
Name of Claimant*
Bank Account Details
Name of Payee*
Bank Name*
Bank Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Bank Account number*
Sort Code
IBAN / BIC number*
Swift code
We do not accept liability for any errors due to the incorrect bank details being provided by you.

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Declaration
*
- I verify that all information contained in this form is true, correct and complete to the best of my knowledge. I authorize any licensed doctor, practitioner of the healing arts, hospital, clinic, health related facility, pharmacy, government agency, insurance company, group policyholder, employee or benefit plan administrator having information as to the care, advice, treatment, diagnosis or prognosis of any physical or mental condition, or the financial or employment status of the person named below, to provide this information to Tangiers International. I understand that I have the right to receive a copy of this authorization upon request. A copy of this shall be as valid as the original. This authorization is valid for twelve months from the date signed
Name*
Date*
Email
This field is for validation purposes and should be left unchanged.

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Description of lost, stolen or damaged property	Date of purchase	Original purchase price in EURO	Value at the time of loss after allowing for wear and tear in EURO	Net amount claimed in EURO

Type of Baggage	Manufacturer	Size	Colour	Date Purchased	Original Cost

Claims form

Currency	Amount