PLEASE READ THESE GUIDANCE NOTES BEFORE COMPLETING THE CLAIM FORM

1. Please complete each section under which you are claiming in full.

2. If you are claiming under your IDEC policy, please complete the Medical Section of the claim form.

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

4. 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   Fax
Email   Diver qualification
Date of birth   Nationality
Occupation Country of residence

Travel/Tour operator

  Country of destination
Policy/Booking number Date insurance purchased
Departure date Return date
 

PLEASE NOW FULLY COMPLETE EACH SECTION OF THE CLAIM FORM UNDER WHICH
YOU WISH TO CLAIM. THE SECTIONS ON THIS CLAIM FORM CORRESPOND WITH
THOSE ON YOUR TRAVEL INSURANCE CERTIFICATE FOR EASE OF REFERENCE
 
SECTION A - BAGGAGE
Place of damage / theft / loss Date and time of damage / theft / loss

Full details of circumstances:

Was loss/damage reported to: If No to any, please state reason why in the box above  
the courier Yes No  
the airline Yes No  
the police Yes No  
What was the total value of all baggage and personal effects carried on your trip?
Total amount claimed for baggage
Are the items solely your property? If No, please explain in the text box above Yes No

Insurers contribute to the settlement of each others claims, which shares costs and helps to keep premiums down.
Please give full details of your household contents policy
Policy number
Insurers name
Insurers address
Have you ever made an insurance claim for personal property? Yes No
If Yes, please give precise details in the box below        
Has a claim been submitted to any other insurer or any authority in respect of this loss? Yes No
If Yes, please give precise details in the box below        

Details of other insurers / previous losses:

TEMPORARY LOSS OF BAGGAGE
Total number of hours baggage was delayed / lost
Total amount claimed for baggage delayed / lost

Insurers require claims to be supported by evidence of ownership and original purchase price.
Please mail original purchase receipts, guarantee cards, instruction manuals, credit card slips/statements or original insurance valuations to confirm ownership of the items being claimed.
Replacement estimate/receipts do not prove ownership and are not acceptable.

In the box below, provide a full description of the articles lost or damaged and the extent of damage where applicable, the shop/store and location where purchased, date and year of purchase, initial owner, original amount paid and amount claimed.

Details of articles lost:

 
SECTION B - PERSONAL MONEY
Place of theft / loss Date and time of theft / loss

Full details of circumstances:

Was the loss reported to the police? If No, please state reason why in the box above Yes No
Did the money belong to you personally? If No, please explain in the text box above Yes No
Is there any other relevant policy that may cover your money? Yes No
If Yes, please give precise details in the box below        
Have you ever made an insurance claim for personal money? Yes No
If Yes, please give precise details in the box below        
Has a claim been submitted to any other insurer or any other authority in respect of this loss? Yes No
If Yes, please give precise details in the box below        

Details of other insurers:

Total amount claimed for personal cash
Total amount claimed for travellers cheques
 
SECTION C - PERSONAL ACCIDENT
Place of accident / injury Date and time of accident / injury
Full details of circumstances:

Details of injuries sustained:

Total amount claimed for personal accident
 
SECTION D - CANCELLATION AND CURTAILMENT CHARGES
Reason for cancellation
If the cancellation was caused by a person not travelling and not insured on your policy, what relationship is the person to you?
Booking date   Date cancelled
Amount of deposit paid   Date deposit paid
Amount of balance paid   Date balance paid
Amount refunded   Date refunded
Total amount claimed for cancellation
 
If the cancellation is medically related, the medical certificate must be completed by the usual Doctor for the person whose condition caused cancellation of the trip and mailed to Dive Master.
For PDF.file download click here and then click "Back" to return to this form.
 
Reason for curtailment   Date of return
Were you accompanied? Yes No    If Yes, by whom?

In case of early return through illness, bereavement or injury,
please provide full details of the additional expenses:

Total amount claimed for curtailment

If the curtailment is medically related, please forward written confirmation from the doctor abroad that it was medically necessary for you to curtail your holiday.
 
SECTION E - MEDICAL AND EMERGENCY EXPENSES
Place of accident / injury Date and time of accident / injury

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 contact the emergency service as on the policy? 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
 
SECTION F - PERSONAL LIABILITY
Place of incident Date and time of incident
Name of holiday residence / hotel
Address of holiday residence / hotel
Have you admitted liability? Yes No

If you have admitted liability, please explain why and give full details of circumstances:
Please note that any correspondence received from any third party is to be forwarded to us unanswered.
 
SECTION G & H - DELAYED OR MISSED DEPARTURE
Delayed departure claims:
Scheduled date and time of departure Flight / Ferry Nr.
Actual date and time of departure Flight / Ferry Nr.
Airline / Ferry company  
Total number of hours delayed  
Did you cancel your holiday after a delay of more than 24 hours? Yes No
Missed departure claims:
Point of departure of trip
Point of connection failure
Method of transport used to reach point of departure
As a result of you missing the departure, did you miss
the departure of your Liveaboard accommodation?
 Yes No

Please give reason(s) for the delayed or missed departure and explain
which means were employed to rejoin the holiday / trip:

Total amount claimed for delayed or missed departure
 
SECTION I - LOSS OF PASSPORT
Place of loss Date and time of loss
Was the loss reported to the police? If No, please state reason why in the box below Yes No

Full details of the circumstances:

Total amount claimed for loss of passport
 
SECTION J - HOSPITAL INCONVENIENCE BENEFIT
Place illness was
first diagnosed 		Date and time illness
was first diagnosed
Hospital name and address
Total number of days of hospitalisation
Date & time ad-
mitted to hospital 		Date & time discharged from hospital
Total amount claimed for hospital inconvenience
 

SECTION K - LEGAL EXPENSES & ADVICE
Full details of the circumstances and legal advice:

Total amount claimed for legal expenses and advice
 
SECTION L - LOSS OF ACTIVITY / DIVING DAYS
Place illness was
first diagnosed 		Date and time illness
was first diagnosed
Total number of days you were unable to dive due to illness

Full details of the circumstances leading to loss of activity / diving days:

Total amount claimed for loss of activity / diving days
 

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 return to this form)

Details of documents required to support claims: for PDF.file download click here (click on back to return to 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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