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Evacuation & Repatriation

Emergency e-Claim Form

Secure submission • Confidential

Form ID: EVAC-CLAIM-2025

Evacuation & Repatriation Claim Form

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.

Evacuation & Repatriation Claim Form

Please complete this form in BLOCK LETTERS and attach all supporting documents.

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:	_________________________________________
Claimant 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

Emergency Transport Date:	_________________________________________
Transport Description:	_________________________________________
Amount (USD):	_________________________________________
Repatriation Date:	_________________________________________
Repatriation Description:	_________________________________________
Amount (USD):	_________________________________________
Medical Expense Date:	_________________________________________
Medical Description:	_________________________________________
Amount (USD):	_________________________________________
Other Expense Date:	_________________________________________
Other Expense Description:	_________________________________________
Amount (USD):	_________________________________________

5 — Payment Information

Preferred Payment Method:	_________________________________________
Bank Name:	_________________________________________
Account Number:	_________________________________________
Account Holder Name:	_________________________________________
SWIFT / IBAN:	_________________________________________

6 — Declaration & Signature

Declaration Date:

_________________________________________

Signature:

Birdview Insurance • Confidential Claim Document