{"id":2218,"title":"International Travel Insurance Claim Form","purpose":"claim","insurer":{"slug":"icici-lombard-general-insurance","name":"ICICI LOMBARD General Insurance Company Limited"},"source_pdf":"https://www.icicilombard.com/docs/default-source/default-document-library/international-travel-insurance-claim-form8c0007ff45fd68ff8a0df0055f5f6a28.pdf","sha256":"523a565a9c9be10a7bc65770c64914a8d2df21b57d98ed2bb6a098df3526c269","pages":20,"collected":"2026-10-20","instructions":{"about":"This form is used by the insured or claimant to file a claim under the International Travel Insurance policy for various coverages such as medical treatment, baggage loss, trip cancellation, and others.","notes":["Use original bills only.","Answer all questions completely; attach additional sheets if needed.","Claims must be accompanied by original ticket/ boarding pass or copy of passport indicating travel dates.","Failure to immediately notify helpline may reduce claim admissibility to 75%.","No expenses beyond US$ 1000 without prior approval.","Deductible amount as per policy schedule must be borne by insured.","Cashless treatment facility is at company's discretion and not a right.","For baggage claims, proof of ownership is required for items valued at US$ 100 or more.","If compensation is received from carrier after claim payment, insured must refund excess amount to company.","If lost baggage is found after claim payment, insured must take delivery and refund company accordingly.","In case of passport loss, if original passport is recovered before emergency certificate or duplicate passport is issued, insured must notify authorities and refund any refunded amounts to company.","For trip cancellation or delay claims, submit confirmation from carrier, original tickets, hotel bills, and receipts for refunds.","For bounced bookings, insured must claim from carrier or accommodation provider and refund any recoveries to company."],"title":"International Travel Insurance Claim Form","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Insured Details","fields":[{"help":"","type":"text","label":"Policy No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter the policy start date","type":"date","label":"Policy Start Date:","options":[],"required":null,"pdf_field":""},{"help":"Enter the policy end date","type":"date","label":"Policy End Date:","options":[],"required":null,"pdf_field":""},{"help":"Full name of the insured","type":"text","label":"Full Name:","options":[],"required":null,"pdf_field":""},{"help":"Date of birth of the insured","type":"date","label":"Date of Birth:","options":[],"required":null,"pdf_field":""},{"help":"Select the sex of the insured","type":"choice","label":"Sex:  Male         Female","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Current residential address","type":"text","label":"Current Address:","options":[],"required":null,"pdf_field":""},{"help":"Address in country of residence","type":"text","label":"Address in Country of Residence:","options":[],"required":null,"pdf_field":""},{"help":"Phone number while overseas","type":"phone","label":"Phone No. Overseas:","options":[],"required":null,"pdf_field":""},{"help":"Phone number in India","type":"phone","label":"Phone No. India:","options":[],"required":null,"pdf_field":""},{"help":"Mobile phone number","type":"phone","label":"Mobile No:","options":[],"required":null,"pdf_field":""},{"help":"Email address","type":"email","label":"Email ID:","options":[],"required":null,"pdf_field":""},{"help":"Passport number","type":"text","label":"Passport No.:","options":[],"required":null,"pdf_field":""},{"help":"Claim reference number if provided","type":"text","label":"Claims Ref No.:(As provided)","options":[],"required":null,"pdf_field":""}],"filled_by":"insured or claimant"},{"title":"Claimant Information (If different than Insured)","fields":[{"help":"Full name of claimant","type":"text","label":"Full Name:","options":[],"required":null,"pdf_field":""},{"help":"Date of birth of claimant","type":"date","label":"Date of Birth:","options":[],"required":null,"pdf_field":""},{"help":"Select sex of claimant","type":"choice","label":"Sex: Male        Female","options":["Male","Female"],"required":null,"pdf_field":""},{"help":"Relationship to insured","type":"text","label":"Relationship with the Policyholder:","options":[],"required":null,"pdf_field":""},{"help":"Address of claimant","type":"text","label":"Claimant's Address:","options":[],"required":null,"pdf_field":""},{"help":"Office phone number","type":"phone","label":"Phone No. (Off):","options":[],"required":null,"pdf_field":""},{"help":"Residence phone number","type":"phone","label":"Phone No. (Res):","options":[],"required":null,"pdf_field":""},{"help":"Email address","type":"email","label":"Email ID:","options":[],"required":null,"pdf_field":""},{"help":"State your capacity (e.g. insured, nominee, legal heir)","type":"text","label":"In what capacity are you making this claim?","options":[],"required":null,"pdf_field":""}],"filled_by":"claimant"},{"title":"Declaration","fields":[{"help":"Date of signing","type":"date","label":"Dated:","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""},{"help":"Signature of claimant or insured","type":"signature","label":"Claimant's/ Insured's Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant or insured"},{"title":"Authorization by Insured/ On Behalf of the Insured","fields":[{"help":"Signature authorizing release of information","type":"signature","label":"SIGNED (Claimant or authorized person)","options":[],"required":true,"pdf_field":""},{"help":"Relationship to insured","type":"text","label":"Relationship with the Insured","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Dated:","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""},{"help":"Signature of insured","type":"signature","label":"Insured's Signature","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant or authorized person"},{"title":"Annexure 1: Medical Cover & Dental Treatment","fields":[{"help":"List each treatment or expense with date and amount in foreign currency","type":"table","label":"Sr. No. Details of treatment/ expenses Date Expenses in Foreign Currency Total:","options":[],"required":true,"pdf_field":""},{"help":"Describe the illness or injury","type":"text","label":"Nature of Ailment:","options":[],"required":true,"pdf_field":""},{"help":"Provide diagnosis and treatment details","type":"text","label":"State Diagnosis and nature of treatment taken:","options":[],"required":true,"pdf_field":""},{"help":"Treatment start and end dates","type":"date","label":"Dates of treatment: From To","options":[],"required":true,"pdf_field":""},{"help":"Date symptoms began","type":"date","label":"Date of onset of symptoms:","options":[],"required":true,"pdf_field":""},{"help":"Contact details of treating medical provider","type":"text","label":"Name, address & telephone number of consulting physician/ dentist/ hospital where treatment was taken:","options":[],"required":true,"pdf_field":""},{"help":"Indicate if previously treated for this illness and provide details if yes","type":"yes-no","label":"Have you ever been treated for this illness before: Yes No If yes, provide name, address & telephone number of consulted physician:","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Family or regular doctor contact details","type":"text","label":"Provide name, address & telephone number of your family/ regular doctor in India:","options":[],"required":true,"pdf_field":""},{"help":"List current prescription medicines","type":"text","label":"Provide name of any prescription medicine you are presently taking:","options":[],"required":false,"pdf_field":""},{"help":"Name of hospitalized person","type":"text","label":"Hospitalisation Full Name:","options":[],"required":false,"pdf_field":""},{"help":"Hospital address","type":"text","label":"Address:","options":[],"required":false,"pdf_field":""},{"help":"Hospital phone number","type":"phone","label":"Phone Number of Hospital/ Clinic:","options":[],"required":false,"pdf_field":""},{"help":"Doctor's name and qualifications","type":"text","label":"Treating Doctor's Name & Qualifications:","options":[],"required":false,"pdf_field":""},{"help":"Doctor's mobile number","type":"phone","label":"Treating Doctor's Telephone Number: (M)","options":[],"required":false,"pdf_field":""},{"help":"Hospital treatment dates","type":"date","label":"Dates of Treatment: From To","options":[],"required":false,"pdf_field":""},{"help":"Date symptoms started","type":"date","label":"Date of onset of Symptoms:","options":[],"required":false,"pdf_field":""},{"help":"Date and time doctor was contacted","type":"text","label":"Attending Doctor's Report Date Doctor Contacted: Time:","options":[],"required":false,"pdf_field":""},{"help":"Doctor's report on ailment","type":"text","label":"Nature of Ailment:","options":[],"required":false,"pdf_field":""},{"help":"Doctor's diagnosis and treatment details","type":"text","label":"State diagnosis and nature of treatment provided:","options":[],"required":false,"pdf_field":""},{"help":"Date symptoms first appeared","type":"text","label":"When did patient's symptoms first appear?","options":[],"required":false,"pdf_field":""},{"help":"Other medical conditions affecting current illness","type":"text","label":"Describe any other disease or infirmity affecting present condition:","options":[],"required":false,"pdf_field":""},{"help":"Indicate if pregnancy related","type":"yes-no","label":"Was the ailment due to Pregnancy: Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if pre-existing condition aggravated illness and provide details","type":"yes-no","label":"Was the ailment aggravated due to any pre-existing condition? Yes No If yes, please give details:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if evacuation is possible","type":"yes-no","label":"Can the patient be evacuated back to the Republic of India? Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Explain need for medical evacuation","type":"text","label":"Is Medical Evacuation back to Republic of India needed? Please give detailed reasons of the ailment and reason for transportation:","options":[],"required":false,"pdf_field":""},{"help":"Tick if claiming daily allowance","type":"checkbox","label":"Claiming also for daily allowance","options":[],"required":false,"pdf_field":""}],"filled_by":"insured or claimant"},{"title":"Annexure 2: Repatriation of Remains","fields":[{"help":"Describe cause and circumstances of death","type":"text","label":"Cause/ Circumstances of death:","options":[],"required":true,"pdf_field":""},{"help":"Date of insured's death","type":"date","label":"Date of death of Insured:","options":[],"required":true,"pdf_field":""},{"help":"List expenses with dates and amounts in foreign currency","type":"table","label":"Details of expenses incurred for repatriation of Remains/ Funeral: Sr. No. Details of expenses Date Expenses in Foreign Currency Total:","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant or insured"},{"title":"Annexure 3: Checked-In Baggage Loss/ Delay","fields":[{"help":"Describe loss or delay details","type":"text","label":"Describe when & where the Loss/ Delay took place:","options":[],"required":true,"pdf_field":""},{"help":"Describe extent of loss or delay","type":"text","label":"State the extent of Delay/ Loss:","options":[],"required":true,"pdf_field":""},{"help":"Name of airline or carrier","type":"text","label":"Name the common carrier:","options":[],"required":true,"pdf_field":""},{"help":"Airport or port where delay or loss occurred","type":"text","label":"Port of Delay/ Loss:","options":[],"required":true,"pdf_field":""},{"help":"Actual arrival date and time","type":"date","label":"Actual Date & Time of Arrival of flight at Port:","options":[],"required":true,"pdf_field":""},{"help":"Date and time bags were delivered","type":"date","label":"Actual Date & Time when Bags were delivered:","options":[],"required":true,"pdf_field":""},{"help":"Number of hours baggage was delayed","type":"number","label":"No. of Hours of bag delay:","options":[],"required":true,"pdf_field":""},{"help":"Indicate if carrier was notified","type":"yes-no","label":"Had the common carrier been notified at the time of loss?  Yes No","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Details of any compensation from carrier","type":"text","label":"Details of compensation received from carrier:","options":[],"required":false,"pdf_field":""},{"help":"List lost items with purchase dates and costs","type":"table","label":"Sr. No. Item Purchased/ Items Lost Date of Purchase Cost in Foreign Currency (In INR for loss claim) Total: Compensation From Airlines: Net Amount:","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant or insured"},{"title":"Annexure 4: Passport Loss","fields":[{"help":"Describe incident of passport loss","type":"text","label":"Please provide details of the incident leading to loss of passport","options":[],"required":true,"pdf_field":""},{"help":"Date passport was lost","type":"date","label":"Date of loss of Passport:","options":[],"required":true,"pdf_field":""},{"help":"Place where passport was lost","type":"text","label":"Place of loss of Passport:","options":[],"required":true,"pdf_field":""},{"help":"Costs for new passport","type":"amount","label":"Expenses incurred in obtaining new passport:","options":[],"required":true,"pdf_field":""},{"help":"List expenses with dates and amounts","type":"table","label":"Sr. No. Details of Expenses Date Expenses in Foreign Currency Total:","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant or insured"},{"title":"Annexure 5: Personal Liability","fields":[{"help":"Date liability loss occurred","type":"date","label":"Date of Loss:","options":[],"required":true,"pdf_field":""},{"help":"Place where loss occurred","type":"text","label":"Place of Loss:","options":[],"required":true,"pdf_field":""},{"help":"Name of third party affected","type":"text","label":"Name of aggrieved Third Party:","options":[],"required":true,"pdf_field":""},{"help":"Amount claimed for liability","type":"amount","label":"Amount of Liability:","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant or insured"},{"title":"Annexure 6: Personal Accident & Accidental Death (Common Carrier)","fields":[{"help":"Describe accident circumstances","type":"text","label":"Please state circumstances of accident i.e. how, when, where it took place:","options":[],"required":true,"pdf_field":""},{"help":"Describe injury","type":"text","label":"Nature of Injury:","options":[],"required":true,"pdf_field":""},{"help":"Diagnosis and treatment details","type":"text","label":"State diagnosis and nature of treatment/ surgery under taken:","options":[],"required":true,"pdf_field":""},{"help":"Hospital or clinic contact details","type":"text","label":"Provide name, address & telephone number of Hospital/ Clinic:","options":[],"required":true,"pdf_field":""},{"help":"Doctor's name and qualifications","type":"text","label":"Treating Doctor's Name & Qualifications:","options":[],"required":true,"pdf_field":""},{"help":"Doctor's office and mobile numbers","type":"phone","label":"Treating Doctor's Telephone Number: (O) (M)","options":[],"required":true,"pdf_field":""},{"help":"Treatment dates","type":"date","label":"Dates of treatment: From To","options":[],"required":true,"pdf_field":""},{"help":"Date and time doctor was contacted","type":"text","label":"Attending Doctor's Report Date doctor contacted: Time:","options":[],"required":true,"pdf_field":""},{"help":"Doctor's report on ailment","type":"text","label":"Nature of Ailment:","options":[],"required":true,"pdf_field":""},{"help":"Diagnosis and treatment details","type":"text","label":"State diagnosis and nature of treatment provided:","options":[],"required":true,"pdf_field":""},{"help":"Other medical conditions affecting current condition","type":"text","label":"Describe any other disease or infirmity affecting present condition:","options":[],"required":false,"pdf_field":""},{"help":"Indicate if pregnancy related","type":"yes-no","label":"Was the accident due to Pregnancy: Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if pre-existing condition contributed and provide details","type":"yes-no","label":"Was the accident due to any pre-existing condition:  Yes No If yes, please give details:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if evacuation is possible","type":"yes-no","label":"Can the patient be evacuated back to the Republic of India?   Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick applicable loss type and provide details if disability","type":"checkbox","label":"Loss Incurred (Please tick): Death Permanent Total Disability Permanent Partial Disability","options":["Death","Permanent Total Disability","Permanent Partial Disability"],"required":true,"pdf_field":""}],"filled_by":"claimant or insured"},{"title":"Annexure 7: Hijack Distress Allowance","fields":[{"help":"Name of airline or carrier","type":"text","label":"Name of Carrier:","options":[],"required":true,"pdf_field":""},{"help":"Location where hijack occurred","type":"text","label":"Port of Hijack:","options":[],"required":true,"pdf_field":""},{"help":"Location where release occurred","type":"text","label":"Port of Release:","options":[],"required":true,"pdf_field":""},{"help":"Hijack start and end dates","type":"date","label":"Dates of Hijack: From To","options":[],"required":true,"pdf_field":""},{"help":"Hijack start time","type":"text","label":"Time of Hijack: From","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant or insured"},{"title":"Annexure 8: Emergency Cash Advance Assistance","fields":[{"help":"Date of loss of travel funds","type":"date","label":"Date of Loss:","options":[],"required":true,"pdf_field":""},{"help":"Explain reason for loss","type":"text","label":"Reason and circumstances of Loss:","options":[],"required":true,"pdf_field":""},{"help":"List items lost","type":"text","label":"Items lost:","options":[],"required":true,"pdf_field":""},{"help":"Value of lost items","type":"amount","label":"Value of the Items lost:","options":[],"required":true,"pdf_field":""},{"help":"Signature of claimant or authorized person","type":"signature","label":"SIGNED (Claimant or authorized person)","options":[],"required":true,"pdf_field":""},{"help":"Relationship to insured","type":"text","label":"Relationship with the Insured:","options":[],"required":null,"pdf_field":""},{"help":"Date of signing","type":"date","label":"Dated:","options":[],"required":true,"pdf_field":""},{"help":"Place of signing","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant or insured"},{"title":"Annexure 9: Home Insurance","fields":[{"help":"Property address","type":"text","label":"Address of property where loss was sustained:","options":[],"required":true,"pdf_field":""},{"help":"Date loss occurred","type":"date","label":"Date of Loss:","options":[],"required":true,"pdf_field":""},{"help":"Cause of loss","type":"text","label":"Cause of Loss:","options":[],"required":true,"pdf_field":""},{"help":"Describe loss details and circumstances","type":"text","label":"Exact description of nature of loss and it causes (in case of burglary, how was forceful entry gained into the premises and who is suspected of the same):","options":[],"required":true,"pdf_field":""},{"help":"Who was present or discovered loss","type":"text","label":"Occupants of the premises at the time of loss/ by whom it was discovered:","options":[],"required":true,"pdf_field":""},{"help":"Indicate if loss was reported and provide details","type":"yes-no","label":"Has the loss been reported to the proper authorities? Yes No Please give details of where and to whom the loss has been reported along with the date and time (If not reported, please give reasons for the same):","options":["Yes","No"],"required":true,"pdf_field":""},{"help":"Other insurance details if any","type":"text","label":"Details of any other insurance cover for the property:","options":[],"required":false,"pdf_field":""},{"help":"List lost items and amounts","type":"table","label":"Details of Loss Incurred: Sr. No. Items lost due to fire/ burglary Amount Total:","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant or insured"},{"title":"Annexure 10: Trip Cancellation & Interruption","fields":[{"help":"Tick applicable claim type","type":"checkbox","label":"Trip Cancelled/ Trip interrupted/ Also claiming for Trip Regained","options":[],"required":true,"pdf_field":""},{"help":"Explain reason for cancellation or interruption","type":"text","label":"Reason for Trip Cancellation/ Interruption:","options":[],"required":true,"pdf_field":""},{"help":"Detailed explanation","type":"text","label":"Please detail out the above reason for trip cancellation/ interruption (how, where, when and reason for the same):","options":[],"required":true,"pdf_field":""},{"help":"Date of cancellation or interruption","type":"date","label":"Trip Cancellation/ Interruption date:","options":[],"required":true,"pdf_field":""},{"help":"Original trip start date and time","type":"date","label":"Original Travel Dates: From: Time:","options":[],"required":true,"pdf_field":""},{"help":"Name and relationship of affected person","type":"text","label":"Person Affected and Relationship with the Insured:","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant or insured"},{"title":"Annexure 11: Missed (Flight) Connection","fields":[{"help":"Flight causing missed connection","type":"text","label":"Which flight was delayed causing a missed connection?","options":[],"required":true,"pdf_field":""},{"help":"Explain reason for delay","type":"text","label":"Reason for delay of the flight:","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant or insured"},{"title":"Annexure 12: Trip Delay","fields":[{"help":"Explain reason for trip delay","type":"text","label":"Reason for Trip Delay:","options":[],"required":true,"pdf_field":""},{"help":"Detailed explanation","type":"text","label":"Please detail out the reason for trip delay (how, where, when, what was lost and reason for the same):","options":[],"required":true,"pdf_field":""},{"help":"Original trip dates","type":"date","label":"Original Travel Dates:  From: To:","options":[],"required":true,"pdf_field":""},{"help":"Date trip was delayed","type":"date","label":"Trip delayed on:","options":[],"required":true,"pdf_field":""},{"help":"Name and relationship of affected person","type":"text","label":"Person Affected and Relationship with the Insured:","options":[],"required":true,"pdf_field":""},{"help":"List expenses incurred due to delay","type":"table","label":"Details of Expenses Incurred: Sr. No. Loss/ Expenses Details Amount Total:","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant or insured"},{"title":"Annexure 13: Bounced Bookings- Airlines/ Hotels","fields":[{"help":"Explain reason for bounced booking","type":"text","label":"Reason for Bounced Booking:","options":[],"required":true,"pdf_field":""},{"help":"Detailed explanation","type":"text","label":"Please detail out the reason for the Bounced Booking (how, where, when, and reason for the same):","options":[],"required":true,"pdf_field":""},{"help":"Original booking dates","type":"date","label":"Original Travel/ Accommodation Dates: From: To:","options":[],"required":true,"pdf_field":""},{"help":"Number of days booking was bounced","type":"number","label":"Days on which the booking was bounced:","options":[],"required":true,"pdf_field":""},{"help":"List expenses incurred","type":"table","label":"Details of Expenses Incurred: Sr. No. Loss/ Expenses Details Amount Total:","options":[],"required":true,"pdf_field":""}],"filled_by":"claimant or insured"},{"title":"Annexure 14: Compassionate Visit","fields":[{"help":"Select who was hospitalized","type":"choice","label":"Person Hospitalised: Insured Family Member","options":["Insured","Family Member"],"required":true,"pdf_field":""},{"help":"Name of hospitalized person if not insured","type":"text","label":"Name of the person hospitalized (if not the Insured):","options":[],"required":false,"pdf_field":""},{"help":"Relationship to insured","type":"text","label":"Relationship with the Insured:","options":[],"required":false,"pdf_field":""},{"help":"Hospital or clinic contact details","type":"text","label":"Provide name, address & telephone number of Hospital/ Clinic:","options":[],"required":true,"pdf_field":""},{"help":"Doctor's name and qualifications","type":"text","label":"Treating Doctor's Name & Qualifications:","options":[],"required":true,"pdf_field":""},{"help":"Doctor's office and mobile numbers","type":"phone","label":"Treating Doctor's Telephone Number:(O) (M)","options":[],"required":true,"pdf_field":""},{"help":"Hospitalization start date and time","type":"date","label":"Dates of hospitalisation: From: Time:","options":[],"required":true,"pdf_field":""},{"help":"Date symptoms started","type":"date","label":"Date of onset of symptoms:","options":[],"required":true,"pdf_field":""},{"help":"Date and time doctor was contacted","type":"text","label":"Attending Doctor's Report Date on which doctor was contacted: Time:","options":[],"required":true,"pdf_field":""},{"help":"Doctor's report on ailment","type":"text","label":"Nature of Ailment:","options":[],"required":true,"pdf_field":""},{"help":"Diagnosis and treatment details","type":"text","label":"State diagnosis and nature of treatment provided:","options":[],"required":true,"pdf_field":""},{"help":"Date symptoms first appeared","type":"text","label":"When did patient's symptoms first appear?","options":[],"required":false,"pdf_field":""},{"help":"Other medical conditions affecting current condition","type":"text","label":"Describe any other disease or infirmity affecting present condition:","options":[],"required":false,"pdf_field":""},{"help":"Indicate if pregnancy related","type":"yes-no","label":"Was the ailment due to Pregnancy: Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if pre-existing condition aggravated illness and provide details","type":"yes-no","label":"Was the ailment aggravated due to any pre-existing condition? Yes No If yes, please give details:","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if evacuation is possible","type":"yes-no","label":"Can the patient be evacuated back to the Republic of India? Yes No","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Estimated remaining hospitalization time","type":"text","label":"Estimated time the patient would continue to be in the hospital?","options":[],"required":false,"pdf_field":""}],"filled_by":"claimant or insured"}],"deadlines":["Police report for Emergency Cash Advance Assistance must be filed within 24 hours of becoming aware of loss"],"applies_to":"International Travel Insurance claims for various coverages as per the annexures listed (e.g. Medical Cover, Repatriation of Remains, Baggage Loss, Passport Loss, Personal Liability, etc.)","attachments":["Original ticket/ boarding pass or copy of passport indicating travel dates","Original bills, receipts, credit card slips pertaining to claim","Doctor's Report as per format for Accident & Medical Section","Medical reports and discharge summary for Medical Cover","Bills/ receipts for hospital accommodation, nursing, medical services, tests, medicines","Photocopy of death certificate and postmortem certificate for Repatriation of Remains","Proof of expenses for disposal and transportation of mortal remains","Statement of claim and property irregularity report for Checked-In Baggage Loss/ Delay","Police Report for Passport Loss","Statement of claim for Passport Loss expenses","Police report for Personal Liability claims","Medical reports and death certificate for Personal Accident claims","Certificate of Hijack for Hijack Distress Allowance","Police report filed within 24 hrs for Emergency Cash Advance Assistance","First Information Report, Panchnama, Investigation Report, Fire Brigade Report, repair bills, invoices, legal opinion for Home Insurance","Confirmation of cancellation, original tickets, hotel bills for Trip Cancellation & Interruption","Confirmation from Common Carrier, unused tickets, certificates for Missed Flight Connection","Declaration, medical evidence, receipts for Trip Delay","Confirmation from Common Carrier and accommodation provider for Bounced Bookings","Medical certificate, discharge summary, travel tickets for Compassionate Visit"],"declarations":["The information given in this claim form is true, correct and complete.","All persons having interest in the property are disclosed and no duplicate claims have been made.","No material information relevant to the claim has been withheld.","False or fraudulent statements will void the policy and claims.","Receipt of claim form or documents does not admit liability; company may require further information.","Authorization is given to ISM and ICICI Lombard to obtain and share information for claim investigation.","Company may call for additional documents for claim assessment.","Authorization to release information to evaluate and determine coverage is given.","A photographic or facsimile copy of authorization is as valid as original.","Authorization is valid for the duration of the claim.","Fraudulent claims may lead to prosecution."],"dropped_labels":4},"pdf_fields":null,"fillable_pdf":false,"send_to":[],"how_to_use":"Ask the user for each field in order, in plain words; never invent an answer. Labels are as printed. If fillable_pdf is true, pdf_fields gives the PDF's own field names so the file can be filled directly. The printed form decides if anything differs.","url":"https://indiainsurances.com/forms/icici-lombard-general-insurance/2218-international-travel-insurance-claim-form"}