Travel Benefit 1Personal Details2Claim Details3Payment Details Title*MrMrsMsMissDrAdvProfName First Last ID or Passport Number*Cellphone*Email* Policy Number* To calculate your travel benefit we will require the details of the Hospital or medical facility relating to the admission as well as the residential address from where you or your spouse would have commenced travel. Lastly we will also require confirmation of any additional accommodation expenses e.g Invoice form guest house Residential Address* Street Address Address Line 2 City Province Postal Code Name of Hospital or Medical Facility*Address of Hospital or Medical Facility* Street Address Address Line 2 City Province Postal Code Date of admission*DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please attach the account from the medical facility* Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 10 MB, Max. files: 3. Were there any accommodation expenses ?*YesNoPlease attach the relevant receipt or invoice as it relates to the accommodation.* Drop files here or Select files Max. file size: 10 MB, Max. files: 4. Bank Name*Account Type*Cheque/CurrentSavingsTransmissionAccount Number*Account Holder Name*Declaration and Submission* I hereby acknowledge and agree to the below :I hereby declare that all details above as well as any supporting documentation supplied with this claim, are true and correct and I am aware that any non-disclosure or misrepresentation of any details may result in this claim being rejected or my policy being cancelled or voided from inception. Δ
