Air New Zealand - Domestic Claim Form

Part 1: General information (this part of the claim form is compulsory)

d. Your declaration

I/we declare that:

• All statements and particulars stated on this 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 the insurers in the assessment of my claim.

• I/we have not withheld any material information connected with

this claim that will inhibit the insurer’s ability to make a fair and

reasonable assessment of my claim.

• I/we acknowledge that my personal information may be disclosed

to, and obtained from, certain other parties including the Insurance

Claims Register, other insurers and government agencies.

• I/we assign to the insurer all rights of recovery/salvage against any

person or organisation and will cooperate to secure such rights.

Signature of Policyholder(s)

Date

/ /

Policy number

Unsure? Contact your issuing agent to obtain a copy of the Certificate of Insurance.

a. Your information

Title Given name/s Surname Date of birth

/ /

Occupation Mobile phone (or best other contact) Email address

Postal address Suburb City Postcode

b. Payment

If your claim is approved we will deposit your settlement into your nominated account below (we cannot make payments to a credit card)

Name of bank Branch

Account holder name Account number

Please ensure that the bank account details you provide to us are correct. We will not be liable for any loss that you suffer as a result of payment(s)

made to an incorrect bank account because the details you have supplied were incorrect. If you are unsure of your bank account details, please contact

your bank or financial institution for assistance.

c. GST registered companies

Are you registered for GST Purposes?

Yes

Have you claimed or are you entitled to claim GST paid on the insurance policy under which this claim is being made?

Yes

e. Claim details

Date of incident Time Country Town

/ /

AM/PM

Whereabouts/location

Please provide an explanation of your claim and why you are claiming (Please attach a letter if more space is required).

Air New Zealand -

Domestic Claim Form

NB: Original documentation will be

required in order to finalise your claim.

Submit your claim to Cover-More by:

Post: Air New Zealand Claims, C/o Cover-More Claims Department PO Box 105 203, Auckland 1143

Email: [email protected]

REQUIRED DOCUMENTATION FOR ALL CLAIMS

Original itinerary

Certificate of Insurance Air New Zealand Eticket/receipt

Part 2: Amendment or cancellation costs

Please sign below if you would like your Travel Agent to be able to liase with Cover-More on your behalf.

Name of your travel agency Travel consultant’s name

Signature of Policyholder(s) Date

You only need to complete the below for travel arrangements being claimed that were not arranged by a travel agent.

Your policy covers you for amendment or cancellation, whichever is the less (subject to policy limits and the terms and conditions of the Policy Wording).

Firstly you need to work out how much it would cost you to amend your journey (e.g. to travel at a later date) vs. the non-refundable amount you won’t be

able to get back if you cancel the journey. In most cases it is cheaper to amend your journey rather than cancel. If you have not made any changes to your

travel yet as a result of a potential claim under this section, please phone us and we will guide you.

On what date did you cancel/amend your journey?

/ /

Can you travel on different dates?

Yes

No If No, please explain the reason why you have not amended the journey

Flights

(excluding

taxes)

Flight

taxes

Hotels

Packages

Other

(i.e. car hire,

rail passes,

transfers

etc.)

If the trip was cancelled outright prior to departure what would it have cost to amend the trip to different

dates (rather than cancel outright)?

Travel arrangement

Amount paid

Fully refundable

by the airline

B. Amount

refunded by supplier

Cancellation costs

Amount Claimable

(A minus B)

Amendment costs

Total

REQUIRED DOCUMENTATION FOR AMENDMENT AND CANCELLATION COST CLAIMS

A copy of your original itemised invoice for your travel arrangements.

If due to someone’s health (medical condition, injury or death):

Medical Certificate (page 4-5) completed by the usual medical practitioner.

Medical Authority (page 4) completed by the person whose state of health caused the claim or the Executor of the Estate.

Additionally, if the claim is due to someone’s death you will need to provide a full copy of the Death Certificate (not an extract) that states

the cause of death.

[Please note that you can obtain the travel information required below from your travel agent or supplier directly].

Domestic flights documentation (for any domestic flights)

• Air New Zealand: Identify what the specific conditions are for the Air New Zealand fare. e.g. “Seat+Bag”, “Flexitime”, etc and confirm if the

ticket has been changed to travel at a later date or advise what amounts, if any, are being held in credit with the airline.

Land arrangements documentation (for any land bookings)

• We require a copy of the providers booking conditions showing the published cancellation penalties. This is usually shown in the back of the

relevant brochures.

• If the booking conditions do not specify exactly what cancellation fees apply (e.g. cancellation fees may be up to 100%) then we require

written confirmation from the wholesaler confirming how much you are to be refunded.

Part 3: Additional expenses

Please complete this section if you are claiming for expenses incurred as a result of an unforeseen event.

E.g. Accommodation and transport expenses.

Please provide a full description of why the additional expenses were incurred.

Description of cost Amount claimed Description of cost Amount claimed

1. 4.

2. 5.

3. 6.

If the above event had not occurred, what were your original plans for this same time period?

Original plan Cost Original plan Cost

1. 4.

2. 5.

3. 6.

REQUIRED DOCUMENTATION FOR ADDITIONAL EXPENSES CLAIMS

All original invoices and receipts.

If the claim is due to travel delay, you will need to supply a letter from the transport provider that confirms the length and reason for the

delay as well as any compensation offered.

If caused by a medical condition:

If the expenses were incurred due to someone’s health, you will

need to supply a medical report from the treating overseas medical

practitioner confirming the nature of the illness or injury that gave

rise to your claim.

Medical Certificate completed by your usual medical practitioner

(pages 4-5) for claims due to a medical condition, illness or death

(i.e. not an injury).

Medical Authority completed by the patient whose health has

caused the claim or the Executor of the Estate for claims due to a

medical condition, illness or death (i.e. not an injury).

If the expenses were incurred due to someone else’s health

(i.e. someone not on the policy), Medical Certificate (pages 4-5) will

need to be completed by that person’s usual medical practitioner

and Medical Authority will need to be completed by that person.

Medical Form

Submit your claim to Cover-More by:

Post: Air New Zealand Claims, C/o Cover-More Claims Department PO Box 105 203, Auckland 1143

Email: [email protected]

To be completed by the person whose state of health caused the claim (or their Parent/Guardian, Executor of the Estate or Power of Attorney if

applicable). Details of the patient’s usual doctor (of at least 12 months prior to the policy issue date).

I authorise the insurer or its representatives to obtain from any person or organisation any information in respect of treatment for the medical/

dental condition/s/injury/ies or death which resulted in this claim. I acknowledge that a photocopy/scanned copy of this authorisation shall be

considered as valid as the original.

Signature of patient/Executor/Power of Attorney Patient’s name Date of birth

/ /

Relationship to patient (if applicable) Doctor’s or dentist’s phone number Doctor’s or dentist’s email address (preferred contact method)

Doctor’s or dentist’s postal address or fax number (only to be provided if email address is unavailable)

Name of usual doctor or dentist in New Zealand

To be obtained at the claimant’s own expense from the patient’s usual medical practitioner (whom they have been attending for at least 12 months

prior to the issue date of the policy). Required for all claims arising from a person’s health/medical condition, death or dental condition. If you do not

have a usual medical practitioner, please contact us.

IMPORTANT: The medical practitioner is respectfully requested to give as much detail as possible when answering these questions in order to assist

our client with their claim and avoid the necessity of additional questions. PLEASE USE BLOCK LETTERS. You may reply in letter format however

answers to each of the questions below that are relevant to your patient or the claim being made by the claimant will need to be included.

PLEASE INCLUDE ALL PATIENT DISCHARGE SUMMARIES

1. Name of patient 2. Date of birth

/ /

3. Are you the patient’s usual G.P.?

Yes

a. If Yes, for how long? b. If No, do you have access to their medical records?

Yes

From what date?

/ /

4. Please give a precise diagnosis of the illness or injury or cause of death that has given rise to the claim. If an injury, how was it sustained?

5. On what date did the patient first consult you in relation to this condition or symptoms of this condition?

/ /

6. Have you or anyone else known to you previously treated or advised this patient in respect of the same/similar/related illness or injury as

described in the answer to question 4?

Yes

7. Prior to the policy issue date, was the patient receiving any regular advice, treatment or medication or being investigated for this condition or

any similar/related condition?

Yes No If Yes, please give details and please provide details and include copies of all letters from referred

specialists, the patient’s full medical history, current medications and all hospital visits for the past 2 years.

8. Did you advise the patient to take medication for this condition until the journey commenced?

Yes

9. Did you advise the patient to take medication for this condition whilst on the journey?

Yes

10. Was there any indication prior to travel that medical care might be required on the journey?

Yes

11. Please provide details of the patient’s health at the time when the insurance was issued and the likelihood of the patient’s health leading to

hospitalisation or death after this time.

Medical Certiﬁcate (To be completed by the patient’s usual doctor in New Zealand)

Medical Authority (To be completed by the person who was ill/injured)

Signed date

/ /

NZCM_C003_AirNZ Domestic Claim Form_OCT19

Medical Certiﬁcate (page 2 of 2)

12. Please provide the following dates, where applicable.

a. Date of onset of illness/injury/death and/or b. Date tests prescribed c. Date tests carried out

date of deterioration/exacerbation

/ / / / / /

d. Date results advised to the patient e. Date referred to specialist/surgeon f. Date of death

/ / / / / /

g. Name and address of specialist/surgeon

13. Date the patient was advised that they would not be able to travel.

/ /

14. If due to pregnancy:

a. On what date was the pregnancy confirmed? b. How many weeks pregnant was the person on this date?

/ /

c. Was the conception medically assisted?

Yes No

d. Have there been previous complications with this or any other pregnancy?

Yes No

15. Was the patient on a waiting list for hospital?

Yes

No If Yes, please give details.

16. Was the patient hospitalised?

Yes

If Yes, please provide admission date

/ /

I certify that I have examined the patient named above and/or have referred to their medical records and confirm that the information given in this

Medical Certificate is a true and correct statement.

Doctor’s signature Name Date

/ /

Email address, fax number or postal address

Qualification Telephone