Evacuation & Repatriation Claim Form

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Evacuation & Repatriation

Emergency e-Claim Form

Secure submission • Confidential

Form ID: EVAC-CLAIM-2025

Provide accurate information and attach required documents. For repatriation of mortal remains include death certificate and repatriation invoice.

1 — Policy & Personal Details

Insured Person's Full Name*

Policy Number*

Date of Birth*

Contact (phone & email)*

Permanent Address

Occupation

ID / Passport Number

Other Insurance Details (if any)

Emergency Contact (name & phone)

Claimant / Primary Insured Email*

Claimant Relationship*

2 — Trip Details

Trip Destination (Country)*

Reason for Travel*

Travel Agent / Tour Operator

Travel Start Date

Travel End Date

Incident Date*

3 — Incident Details

Circumstances of Incident*

Reason for Evacuation / Repatriation*

Initial Medical Treatment (date & place)

Treating Physician's Name

Reported to Assistance Provider?

Notification Date / Confirmation #

4 — Details of Expenses Claimed

List out-of-pocket expenses and attach itemized bills & receipts.

Emergency Transport Date

Transport Description (air ambulance / ground / escort)

Transport Amount (USD)

Repatriation Date

Repatriation Description

Repatriation Amount (USD)

Medical Expense Date

Medical Description

Medical Amount (USD)

Other Expense Date

Other Expense Description

Other Expense Amount (USD)

5 — Payment Information

Preferred Payment Method*

Bank Name*

Account Number*

Account Holder Name

SWIFT / IBAN

6 — Supporting Documents, Declaration & Signature

Upload scanned copies: medical records, itemized bills, death certificate (if applicable), police report, passport copies, travel itinerary, evacuation invoice, repatriation invoice, proof of payment, exit visa, evacuation authorization letter, flight details.

Upload Supporting Documents

0 file(s) selected

Digital Signature (draw inside the box)

Saved Signature Preview

No signature saved

Declaration Date*

By submitting you declare that the information provided is true and accurate.