Travel delay Missed Departure Missed Connection Claim Form.doc

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CLAIM No ________________________

For Office Use Only

OSG Outsource Services Group Ltd, Merrion Hall, Strand Road, Sandymount, Dublin 4, Ireland

Email : travel@osg.ie

Tel: 00353 (0) 1 6619 133 Fax: 00353 (0) 1 6615 249

Travel Delay / Missed Departure / Missed Connection – Claim Form

OSG Travel Claims are committed to providing a quality service. In order for us to assist you as

quickly and efficiently as possible, it is important that you provide all necessary documentation.

If a claim is received without the correct documentation or the claim form has not been fully

completed, this can delay your claim.

IMPORTANT – Insurers require ORIGINAL documents. You must provide, at your own expense, any documents

required to process your claim. We strongly recommend that you keep copies of all documentation forwarded to us.

Documentation Required :- Failure to provide can result in our being unable to process your claim

Please tick to confirm you have attached the following documents [Tick]

Fully Completed Claim Form

Complete each section. Do not use N/A.

Confirmation of Insurance

Insurance/Validation Certificate. In the case of credit card

Insurance policies, please forward your credit card statement

showing payment of the trip / holiday

Confirmation of Trip Dates

Tour Operators Confirmation Booking invoice. Also Forward

any used / unused travel tickets you may have or any other

documents issues as evidence of the trip

Proof of additional expenses

Original receipts for all additional expenses

Confirmation of the delay

Written confirmation from the carrier (e.g. airline, ship or coach)

advising reasons for and duration of the delayed departure of the

aircraft etc.

If the claim is as a result of a car

breakdown

Provide invoices from garage who attended breakdown & that

the car has had its full service history

Confirmation of any

arrangements made by the

carrier

If flight/sailing was cancelled, provide written confirmation from

the carrier as to when the next available transportation was to

have been provided.

Any Additional

Information/documentation

Any additional information or documents which you wish to

enclose to substantiate your claim

We understand that it can at times be a daunting prospect making a claim. Please help us to help you by

following these guidelines.

• Always send original documentation (We recommend you retain copies)

• Make sure that the claim form is fully completed, and that the information given is as clear as possible

• Always provide the information requested above. If for some reason, the documentation is not

available, please attach a letter advising why it has not been enclosed.

OSG Business Solutions – Travel Claims

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Travel Delay / Missed Departure / Missed Connection – Claim Form Continued

Our aim is to process your claim as efficiently as possible. In order to achieve this please ensure

that you fully complete the form and provide the original documents requested on the Information

Sheet. (We strongly recommend you retain copies). Please note – if the information requested is not supplied,

this can hold up your claim, and we may not be able to process it.

NB. All sections MUST be FULLY completed. (In BLOCK CAPITALS please)

Name of Policy Holder Age

Name of Person to whom any payment

should be made payable to -

If different

from above

Address

What Insurance Company did you take

out your Travel Insurance with?

What Is Your Policy Called / Credit

Card Type?

Post Code (If

Applicable)

Policy / Certificate Number

If Credit Card Please write the

Number (first 7 and last 4

digits only please)

E-Mail address

Policy Issue Date Incident Date

Home Telephone Number

Mobile Telephone

Number

Country of Destination Travel Agent

Departure Date Booking Date

Original Return Date

Actual Return

Date

Tour Operator Occupation

Data Protection

In order to administer your claim, the information provided in this form may be held on computer and/or in manual

files for administration and risk assessment purposes. We may disclose your personal data to and may request

information from other insurance companies for underwriting, claims handling and fraud prevention purposes.

By returning this form, you consent to our processing your personal data for the above purposes.

Claimants signature and declaration

• I declare to the best of my knowledge all particulars in this form are true and accurate, with no omissions of

any material information which would affect the insurers assessment of this claim

• I give permission for any medical practitioner, Police or similar authority mentioned with respect to this

claim to release information regarding my records.

• I am aware that it is a criminal offence to defraud or attempt to defraud an insurer and that by doing so I may

be prosecuted. I am also aware that should any element of this claim be found to be fraudulent in any way, all

elements of the claim will be denied.

• I grant OSG Business Solutions and the Insurers they represent, full rights of subrogation in respect to any

payments made on my behalf. I further agree to fully co-operate with such recovery efforts that Insurers deem

necessary.

Signed Date

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Travel Delay / Missed Departure / Missed Connection – Claim Form Continued

Details of all insured people included in this claim

Forename Surname Age

Date of Incident ________________________

Time and date of Scheduled Departure _______________ Time and date of Actual Departure __________________

Overall duration of delay _____________ (Hours)

Did you abandon your outward trip as a result of the delay and are claiming for the cancellation costs? YES / NO

If Yes, please complete the details in the ‘Additional Expenses’ table below and state ‘original flight’ in the table.

Reason for the interruption of your journey ____________________________________________________________

_______________________________________________________________________________________________

If your flight was cancelled, please advise the reason why ________________________________________________

Please also advise if they accommodated you on the next available flight, or refunded you for the unused element of

your ticket (If so, please advise amount refunded._______________________________________________________

If you were unable to take the next available flight, advise why not and provide written confirmation from the airline

as to when the next available flight would have been ____________________________________________________

Name of the carrier (i.e. airline, ship, coach,) whose aircraft / vehicle / vessel was delayed ______________________

_______________________________________________________________________________________________

If you missed your connecting flight please advise the original departure time ________________________________

And what action you took to continue your journey______________________________________________________

_______________________________________________________________________________________________

Please ensure that all expenses are placed in the additional expenses table below.

Additional Expenses

Receipt

number

Full details of additional expenditure (Enclose all receipts /

flight tickets etc.). Please also state the reason for any

additional travel or accommodation expenses.

Date of Purchase

Receipts?

Please Tick.

Non €

amount

Claimed

Amount

claimed. (€)

TOTAL

Continue on a separate sheet if necessary

Please tally the receipt number with any receipts you may have (write the number on the top of the

receipt).

Please remember to include all ORIGINAL documentation requested on the information sheet:- (Please retain copies for

your records)

Confirmation of Insurance, Booking Invoice, Flight Tickets, Original receipts for all additional expenses (cross referenced on expenses table),

confirmation from the carrier as to the length of and reason for the delay.