FirstAssist - Assistance - Claims Notification

Contact Name
Contact Telephone number
Contact Fax number
Email address
Date
Current Location
Assistance Required
Name of Insured
Home address
Home telephone number
Date of birth
Travel companions Please list names & relationships
Hotel/Accommodation name
Telephone number
Inpatient/Outpatient details only
Diagnosis:
Admission/treatment date
Hospital/Dr name
Address
Telephone number
Fax Number
Previous Medical History
Note: if this section applies, we must receive a completed Medical Consent Form. This form can be downloaded here. It must be signed and forwarded by Fax to +44 20 8763 3035. You will need the free Adobe Acrobat Reader to view this Form If you do not already have this application you can download it from here
Any alcohol or drug involvement - if yes, please provide details
Curtailment details only
Reason for curtailment
If curtailment is for ill or deceased relative, please complete the following:
Cause of illness or death
Relevant dates of illness/hospital admission/death
You must provide us with contact details of relevant hospital/doctor: name and telephone number
Relative's name, date of birth and home address
Insurance Details
Insurance Policy name
Policy number
Name of issuing agent
Agent address
Agent telephone no.
Lead name
Period of Insurance:	from to
Date of issue
Travel Details
Travel dates:	From to
Flight numbers:	Outbound Return
	From to
Tour operator
Book reference
Additional Information - please use this space to provide any further details which you think will be of assistance

Assistance Services