PLEASE READ THESE GUIDANCE NOTES BEFORE COMPLETING THE CLAIM FORM


1. Please complete the MEDICAL SECTION of the claim form.

2. Please ensure that you complete the GENERAL DETAILS and all sections relevant to your claim.

3. Once you have completed your online claim form, please post original of all documents required to support a claim to:

    Dive Master Insurance Consultants Ltd.
    17-23 Rectory Grove
    Leigh-on-Sea
    Essex SS9 2HA

 

GENERAL DETAILS

First name Surname
House name / number   Street
Post code   Town / County
Country   Telephone
Email   Fax
Date of birth   Nationality
Diver qualification Occupation
Policy number Date insurance purchased
Place of illness / injury Date and time of illness / injury

MEDICAL AND EMERGENCY EXPENSES

Details and circumstances of illness suffered or injuries sustained - please include details of medical history

Did you take form EHIC (formerly E111) with you? Yes No
Was it presented? Yes No
Did you notify CEGA? Yes No
Do you hold any private medical insurance, e.g. BUPA, PPP, etc.? Yes No
If Yes, Policy number and Scheme name  
If hospitalised, date / time admitted   date / time discharged
Period of extended accommodation from
(if applicable)		   to
Were any additional expenses incurred in returning home? Yes No
Please supply details of your original return travel arrangements in the text box below.
If you have incurred any additional expenses, ensure that the reasons and costs are included in the box below.

List expenses claimed and treatment received
Total amount claimed for medical and emergency expenses

 

I confirm that all information supplied in this form is true and correct in every aspect and that no relevant information has been withheld. On settlement, all rights of subrogation, salvage and recovery are transferred to the insurer and / or their loss adjuster.

If necessary, download the medical certificate: for PDF.file download click here (click on back to re-enter this form)

Details of documents required to support claims: for PDF.file download click here (click on back to re-enter this form)

Please print a copy of this form and / or the formmail that you will receive upon submitting this form.

 

 

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