Form Instructions

Step 1: You must complete all sections of this form to assist with the assessment of your claim
Step 2: Ensure the Declaration page is signed and witnessed
Step 3: Attach documents that are reasonably required to support your claim
Step 4: Return your form and supporting documents to the below addresses:
Email your form to us Mail your form to us
cardclaims@allianz-assistance.com.au Locked Bag 3014, TOOWONG DC, QLD 4066

Important Information:
• If an eligible person wishes to claim any of these benefits, they will be bound by the eligibility criteria, terms, conditions,
limits and exclusions contained in the insurance information booklet in use as at the date of the loss event.
• Please do not email copies of your credit card statement - If you are required to provide a credit card statement for your claim,
a Claims Consultant will guide you through the process of sending these documents via post.
• Please ensure you keep a copy of your completed claim form and any documentation you submit with your claim

Step 1: Your Details

Title Full name

Policy/reference number Date of birth

Email

Phone Mobile

Address

Suburb State Postcode

.

Please confirm how you would like to receive any written correspondence: Email Post

Authorisation
If you wish to give authority for another person to act on your behalf in respect to this claim you must complete the following
details. Authority may be given to any person/s which may include family members, otherwise we will not be able to give any
information about your claim to any other person. It is important to note that a travel agent cannot manage a claim on behalf of
the customer.

I authorise the following listed person to act on my behalf in relation to this claim:

Name Date of birth

Relationship Phone number

Email

Payment details
Please provide your bank details below for a direct credit to your nominated bank account. If you do not provide the following
details, we will post a cheque. If we are required to make a payment on your behalf, we will contact you to discuss your
payment of any applicable excess.

Please note we cannot credit a credit card/debit card.

Account Name: Bank name

BSB Number Account number

Step 2: Credit Card Details
Q1. First six digits of your credit card Last four digits of your credit card

Q2. Name on card

Q3. Financial Institution

Q4. Card name/type (as outlined on statement)

Q5. Are you a cardholder for this credit account? Yes No

If no, please answer the following questions:

What is the relationship between you and the cardholder? Spouse Dependent Other
If other, please explain

Were you with the cardholder at the time of the incident? Yes No

Do you permanently reside with the cardholder? Yes No

Step 3: Claims History

Q1. Have you made any travel insurance or home and contents insurance claims in the past 5 years? Yes No
If yes, please answer the following:

How many previous claims?

What have you claimed for?

Please describe what you have claimed before and include claim and policy numbers

Step 4: Details of Other Insurance

Q1. Have you lodged or do you intend to lodge a claim for this event elsewhere? Yes No

Q2. Have you received compensation from any other party in relation to this event? Yes No
If yes, please provide full details

Q3. Do you have any other insurance policies that may cover the loss you are claiming for? Yes No
If yes, please provide the following

Name of insurer

Policy number
Step 5: Details of Event & Information Required
Please specify the details of your claim in the below fields

Documents that are reasonably required to support your claim:

• Invoices and/or receipts for items you are claiming showing the last 4 digits of your credit card
and original cost of the item; and

• Printed catalogue advertising the same item at a lower price

If you do not make all reasonable effort to provide this information, it may delay the assessment of your claim.

Store Name Date of Original Lower

Personal Goods Store name Date of Difference
(original original purchase Advertised
claimed (lower price) Catalogue Claimed
purchase) purchase price Price

e.g. Suit Case Bag Store DD/MM/YY $500 AUD Bag Store DD/MM/YY $325 AUD $175 AUD
Name
Declaration
• I/we declare that all statements and particulars stated on this claim form and all documents submitted are true and correct.
• I/we will use my best endeavours and give all reasonable assistance and co-operation to AWP Australia Pty Ltd trading as
Allianz Global Assistance in the assessment of this claim.
• I/we acknowledge that Allianz Global Assistance relies upon the truthfulness of the statements and particulars and
documents submitted in respect of this claim.
• I/we have not withheld any material information connected with this claim that will inhibit the ability of Allianz Global
Assistance to make a fair and reasonable assessment of this claim.
• I/we acknowledge and agree that Allianz Global Assistance may collect, use, and disclose my personal information
including sensitive information in accordance with its Privacy Policy; (see the Privacy section below).
• I/we assign to Allianz Global Assistance all rights of recovery against any person or organisation and will cooperate to
secure such rights.

Authority
I authorise AWP Australia Pty Ltd trading as Allianz Global Assistance to obtain and collect any information relating to me
(including personal information) which Allianz Global Assistance in its absolute discretion considers necessary to assess and
investigate any aspect of this claim, including but not limited to information about any medical treatment and its cost, medical
history, my financial circumstances, and the facts and circumstances which resulted in or are connected with this claim.

I authorise any person, corporation, institution whether public or private, Medicare, doctors, hospitals, medical facilities, and
any entity whatsoever that holds information about me (including 'personal information' as defined in the Privacy Act 1988
(C'th)) to release and provide such information to Allianz Global Assistance which Allianz Global Assistance in its absolute
discretion requests. In the event I am deceased, un-contactable, or have no legal capacity, I authorise Allianz Global
Assistance to pay any policy benefits payable under my policy to my estate or personal representatives, and in the event there
is no will or it cannot be produced or there are no personal representatives lawfully appointed, to my next of kin.

Privacy
By providing your personal information to us (whether by yourself or through someone on your behalf), you agree and consent
to the collection, use, and disclosure of your personal information as set out in our Privacy Policy available on request
(telephone 1800 023 767) or on the web at http://www.allianzpartners.com.au/privacy-and-security.

For example, we may disclose your personal information to third parties (some of whom may be located overseas) such as
external claims handlers and data collectors who assist us manage claims, other insurers, travel agents, your broker, medical
practitioners, your family members, loss adjusters and intermediaries, investigators and the Insurance Reference Service
(IRS), and to our business partners to offer you products and services in which you may be interested. You have the right to
seek access to your personal information at any time. Without your consent to our Privacy Policy, we may not be able to
provide our services to you

Internal Dispute Resolution

Allianz Global Assistance provides an internal dispute resolution process should any dispute arise. Please feel free to ask for
details. If you are not satisfied with the outcome of this process, we will advise you how to contact the insurance industry's
external independent complaints scheme.

Fraud
Insurance fraud places additional costs on honest policyholders. Fraudulent claims force insurance premiums to rise. We
encourage the community to assist in the prevention of insurance fraud. You can help by reporting insurance fraud. All
information will be treated as confidential and protected to the full extent under law. Report insurance fraud by calling Allianz
Global Assistance on 1800 453 937

Signature of claimant Signature of witness

Name of claimant Name of witness

Date Date