Making a claim with Suresave

Before you start

In order for us to process your claim quickly its important
that you complete all the relevant sections of this form with
as much detail as you can. If you do not have enough room
please attach additional information on a separate sheet.
If you are giving authority to another person to
act on your behalf in respect to this claim please
complete the Nominated Authority box below.
Youll find it easier if you first get all your supporting
documents together. You can find a full list of all the
documents we will need on page 11. Use these documents
to complete all relevant sections of the form.

What you need to do:

Step 1 and 2:
These are all about you, your trip and what happened
to cause you to need to make a claim.
Step 3:
This section is divided into specific sections
relevant to different claim types. You only need to
complete section(s) applicable to your claim.
Step 4:
Your bank details so we can transfer any cash
payments for your claim directly.
Step 5:
This is the declaration form, youll need to sign
this in order for us to assess your claim.
Step 6:
The final step is a checklist to help you collate
all your supporting documents.
Where to send the completed form
Check your form thoroughly and make a copy of
everything before you send it to us. Please send us
the originals and keep a copy for your records.
Postal Address:

Email: [email protected]

Travel Claims Department

P.O. Box A975
Sydney NSW 1235
Australia

Fax: +61 2 8263 0494

or 1300 619912

1. You & your policy

Your Policy:
1. Certificate of insurance / Policy number:
Did you contact emergency assistance (Specialty Assist)?

Go to question 2
Yes Give details below
No

Please enter your assistance reference number:

Your Details:
2. Title:

First name:

3. Last name:
4. Date of birth: (DD/MM/YYYY)
/

5. Occupation:
6. Preferred contact number:
7. Email address:
8. Address:

State/region: Postcode:
9. Preferred method of contact:
Email

Phone

Mail

Nominated Authority
I/We authorise:
Name of Nominated Authority:

Address:

Email:
State: Postcode:
Date of birth: (DD/MM/YYYY)
/

Preferred contact number:

to act on my/our behalf in respect to this claim and to be provided with information relating to this claim.
Need some help?

Call: +61 2 8263 0487 or 1300 625 229 Email: [email protected] Date: 05/08/14 Version: 1.0.0

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2. Tell us what happened

Please provide an exact description of the events that caused you to make this claim.

What happened?
Example: I broke my leg/My bag was stolen/My child became ill.

How did it happen?

Please give a detailed account of exactly how the incident occurred.

When?

Where?

Date and time you were first aware of the loss, incident or need to
change or cancel your trip:

Town and Country (eg Paris/France):

(DD/MM/YYYY)

Location (eg Hotel Reception):

(HH:MM)
/

(AM/PM)

Information about your trip

1. When did you first book your travel?
(DD/MM/YYYY)
/
/
2. When was the first payment for your trip?
(DD/MM/YYYY)
/
/
3. When was the last payment for your trip?
(DD/MM/YYYY)
/
/
4. Were you travelling for:
Holiday

Need some help?

Business

5. If you purchased any of your travel arrangements on your credit

card please give details:
Credit Card Provider: (eg National Australia Bank):

Card Type:
Visa

Mastercard

Amex

Other

Card Level:
Standard

Gold

Platinum

Other

If other please specify in the box below:

Call: +61 2 8263 0487 or 1300 625 229 Email: [email protected] Date: 05/08/14 Version: 1.0.0

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3: What are you claiming for?

The next part of this form is divided into specific sections relevant to different claim types. Please complete only the section(s) applicable to
your claim. Specific documents will also be required to support your claim, the Checklist on page 11 will help guide you.

3a - Trip Cancellation or Change

Details of Cancellation or Change
1. Was the cancellation/change due to illness, injury or death?
Yes Go to question 2

No Please advise reason:

Relationship to you:
3. Name of all people whose arrangements
have been cancelled/affected:

2. If cancellation/change was caused by a person please provide

the following:
Name of person causing the trip to be cancelled:
4. Date agent/airline notified:

Their date of birth:

/

(DD/MM/YYYY)

(DD/MM/YYYY)

If your trip was cancelled:

5. Please provide the following details for costs claimed:
Date

Description

Supplier

Amount Paid

Refund Recieved

Amount Claimed

DD/MM/YYYY

Hotel Room

Expedia

$100

$25

$75

Totals:

Please note: If cancellation was caused by death, injury or illness you must also complete Step 3i.
If your trip was changed or postponed:

If you lost Reward Points

6. Total cancellation fee if trip was cancelled outright:

9. Total amount of points used to purchase air ticket:

.
10. Did you pay any additional amount towards this air ticket?

7. Additional amount paid:

$

8. Date trip was rebooked:

/

Yes
(DD/MM/YYYY)

No

11. Total amount of points refunded:

12. Total amount of points lost:
13. Date trip rebooked:
/

Need some help?

(DD/MM/YYYY)

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3b - Additional or Other Expenses Claim

1. List all items you wish to claim for:
Details of Expense

Date of Expense

Amount Claimed

Extra nights accommodation at the Hotel De Paris

DD/MM/YYYY

Currency

. 0

Euro

.
.
.
.
.
.
.
.
.
.
.
.
.
.
.

3c - Delayed Luggage Claim

1. Your arrival date and time at destination:
(DD/MM/YYYY)
(HH:MM)
/

2. Date and time your luggage arrived:

(DD/MM/YYYY)
(HH:MM)
/

(AM/PM)

(AM/PM)

3. Have you made a claim against your carrier?

No

Go to question 4

Yes

What compensation did the carrier pay you?

Amount: Currency:

4. Please provide a list of the essential items purchased:

Name of item purchased

Place of Purchase

Date of Expense

Disposable Razors

Seven Eleven

DD/MM/YYYY

Original Purchase Price

2

Currency

AUD

.
.
.
.
.
.
.
.

Need some help?

Call: +61 2 8263 0487 or 1300 625 229 Email: [email protected] Date: 05/08/14 Version: 1.0.0

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3d - Lost, Stolen or Damaged Luggage & Personal Effects Claim

Your luggage includes your clothing and other personal belongings
designed to be carried about with you or worn. It also includes
passports, visas, tickets and other documents.

9. If not reported, please explain why this

policy requirement was not met:

1. Are you claiming for:

10. Can this be claimed against your household insurance policy?

Loss

Theft

No

2. Date and time Loss/Theft/Damage was discovered:

(DD/MM/YYYY)
(HH:MM)
(AM/PM)
/

Policy number:

Airline/Carrier

Hotel Management

Tour Guide

Other

Amount paid by insurer:

$

If other please give details below:

4. Name of police officer or relevant authority:
5. Job title/position:

11. If you are claiming for spectacles, dentures, or a hearing aid,

are these items claimable against your private health fund?

Go to Question 12
Yes Give details below;
No

Name of fund:

6. Location:

Member number:

7. Report number:

Amount paid by health insurer:

$

8. Date and time reported:

(DD/MM/YYYY)
(HH:MM) (AM/PM)
/

Name of insurer:

3. Who was it reported to?

Police

Go to Question 11
Yes Give details below

Damage

Please note: that if your luggage is delayed, lost or damaged while in the care of the carrier, they may have a responsibility to compensate
you. It is therefore essential that you first claim compensation from the carrier and obtain and provide us with written confirmation of their
response to your claim.
12. List all items you wish to claim for: (Refer to step 3e for Replacement of Travel Documents).
Details of Expense

Place of Purchase

Date of Purchase

Cannon X1 Digital Camera

DigiCameras

DD/MM/YYYY

Purchase Price
5

Currency
4

AUD

.
.
.
.
.
.
.
.
.
.
.

Need some help?

Call: +61 2 8263 0487 or 1300 625 229 Email: [email protected] Date: 05/08/14 Version: 1.0.0

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3e - Replacement of Travel Documents

1. List all items you wish to claim for.
Replacement Documents

Date Replaced

Replacement Cost
(in Foreign Currency)

Passport, visa

DD/MM/YYYY

Currency

GBP

.
.
.
.

3f - Rental Vehicle Insurance Excess Claim

1. Type of vehicle:
Car

Campervan

Minibus

Other

2. Name of vehicle hire company:

Currency:
.

6. Actual repair costs:

Currency:
.

3. Name of person driving the vehicle:

7. Amount you are claiming:

Currency:
.

4. Their date of birth:

/

5. Rental vehicle excess:

(DD/MM/YYYY)

3g - Resumption of Trip Claim

1. List of arrangements cancelled in order to return home:
Cancellation fees:

Date of Expenses from:

Date of Expenses to:

Hotel Ibis

DD/MM/YYYY

DD/MM/YYYY

Amount:

Currency:
1

EUR

.
.
.
.
.
.
2. List of arrangements booked to resume your trip:
Additional Expenses:

Date of Expenses from:

Date of Expenses to:

Air Asia Economy Class Ticket

DD/MM/YYYY

DD/MM/YYYY

Amount:
1

Currency:
2

AUD

.
.
.
.
.
.

Need some help?

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3h - Medical and Dental Expenses Claim

1. Name of Ill/Injured Person:

Yes

2. Their date of birth:

/

7. If an injury occurred, was it whilst taking part

in a snow sport activity (ie. skiing)?

(DD/MM/YYYY)

3. Relationship to you (if not you):

No

8. Name and address of Doctor/Dentist who

treated illness/injury abroad:

4. Nature of illness/injury:
5. Date first occurred:
/

(DD/MM/YYYY)

6. Has the person been treated for this

illness/injury or similar before?

9. Country where Illness/Injury was treated:

10. Were they admitted to hospital?

Yes
No
If YES please give details below:

Yes

No

11. Date and time admitted:

(DD/MM/YYYY)
/

(HH:MM)

12. Date and time discharged:

(DD/MM/YYYY)
/

(AM/PM)

:
(HH:MM)

(AM/PM)

13. Are you claiming for loss of income due to injury?

Yes

No

14. List of medical expenses incurred:

Type of Service:

Date of Expense:

Consultation

DD/MM/YYYY

Need some help?

Cost Incurred:
7

Currency:
8

Account Paid:

GBP

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

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3i - General Practitioner/Dentist Medical Certificate

(Part 1) - To be completed by the person whose state of health caused
the claim or Executor/Guardian of that person (if applicable).
I authorise any hospital, physician or other person who has attended me, to give my travel insurance company or its representative, any, or
all information, with respect to any sickness or injury, medical history, consultation, prescription, or treatment, and copies of all hospital or
medical records. I agree that a photocopy of this authorisation will be considered as effective and valid as the original.
Name of the person whose illness or injury caused the claim:
Their date of birth:
/

Signature:

(DD/MM/YYYY)

(Part 2) - To be completed by your usual General Practitioner/Dentist

This Medical Certificate must be completed at the claimants expense by the usual doctor (G.P.)/
dentist of the person whose illness/injury/death caused this claim.
1. Name of patient:

10. Address of specialist:

2. Their date of birth:

/

(DD/MM/YYYY)

3. Does he/she usually attend your practice?

Go to Question 4
Yes If so, how long?
No

4. Do you have access to the patients medical/clinical records?

Yes
No
5. Please provide a precise diagnosis of the illness/injury:

11. Date referred:

/

12. Date first attended specialist:

/

(DD/MM/YYYY)
(DD/MM/YYYY)

13. Are you aware of referrals to any other

Practitioners/Surgeon/Specialist?

Go to question 14
Yes If so, please provide details:
No

6. Date of the onset of the illness or injury:

(DD/MM/YYYY)
/
/
7. Date on which you were first consulted
for symptoms of illness/injury:
(DD/MM/YYYY)
/
/
8. Did you refer your patient to a specialist?

14. Is the medical condition described caused or exacerbated by,

traceable to, or related to any recurring illness or condition?

Go to question 15
Yes If so, please provide details:
No

Go to question 13
Yes If so, give details:
No

9. Name of specialist:

Need some help?

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15. Please provide details of all medication that your patient

was taking over the past 24 months (regardless of
prescribing physician) and the relating condition.
Condition:
Medication:

Doctors declaration
I declare that I have examined the patient named above and/
or have referred to their medical records and confirm that
the information given is a true and correct statement.
Name of Doctor/Dentist:

Condition:

Signature:

Medication:
Condition:
Medication:

Email:

Condition:
Medication:

Phone:

Condition:
Medication:

Fax:

16. Please give details of any chronic disease or illness or any

physical defect or infirmity from which he/she suffers:

Doctors stamp:

17. Was the patient medically advised not to travel

prior to the commmencement of their trip?

Go to question 18
Yes On what date?
No

(DD/MM/YYYY)

18. Did your patient travel overseas for the purpose of obtaining
medical treatment or advice for medical treatment?

Go to question 19
Yes If so, please provide details:

No

19. Please provide a printout of your patients medical

history and clinical notes (if applicable).

Need some help?

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4: Bank Details
If your claim is approved, we will deposit your refund in
Australian Dollars directly into you nominated account.

Name of bank:

The account nominated must be either a cheque

or statement account. Unfortunately, we are
unable to deposit into a credit card account.

Branch:
Account holders name:
BSB number

Account number

5: Declaration
SureSave claims are handled by the dedicated claims team at
Cerberus Special Risks. Cerberus takes your privacy seriously.
We use the information you provide to us to assess your
claim and pursue any recovery. We may need to provide that
information to other people, for example your insurers and
any assessors, health professionals or others that we need to
assist us in doing this. If you dont provide us with complete
information, we will not be able to properly assess your claim.
You can check the information we hold about you at any time.
For more information about how we use your personal
information, please refer to the Privacy Notice in the SureSave
Product Disclosure Statement or ask us for a copy of our
privacy policy available from www.suresave.net.au.

I/We declare that all information provided is true and correct.

I/We authorise any person or organisation to provide Cerberus or
its representative with any information that they may request in
relation to this claim.
I/We agree that a photocopy of this authorisation is as effective and
valid as the original.
Signature of claimant:

Name of claimant:
Date:
/

(DD/MM/YYYY)

6. Getting your paperwork together

To assess your claim faster, we prefer original documents which may be electronic like eTickets. You can provide us with copies, however we
reserve the right to request the originals or further documentation to support your claim, which may cause delays. If any of the documents are
missing please provide a written explanation or please contact us on +61 2 8263 0487. Original documents will not be returned so please keep
a copy of these documents for your own records.
Please see the final page for a checklist of the documents we will require.

Need some help?

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Documentation Checklist
The following checklist provides you with the documents we require.
For All Claims We Need Your

3e - Replacement of Travel Documents

Proof of your travel dates (e.g. eTickets)

Receipts or invoice of original travel documents

Relevant Credit Card Statements where used to purchase travel

arrangements

Receipts relating to the replacement of travel documents

3a - Trip Cancellation
Booking conditions showing breakdown of all trip costs
Documents confirming refunds provided by travel agency, tour
company, airline, etc.
Proof of payment for trip (ie. receipts, credit card/bank
statements showing payments made)
Completed Medical or Death Certificate (where cancellation due
to medical reasons)
Letter from Transport Provider explaining the circumstances of
the cancellation/refund/compensation
Airline tickets if not refundable
3a - Loss of Reward Points
Original airline ticket (including cost and points)
Reward statement showing total points used, any points charged
as cancellation & any refund of points
3b - Additional Expenses
Receipts or other evidence of expenses paid by you
Evidence from the provider (Airline, Hotel, Bus company)
explaining the circumstances of the expenses
Booking invoice with original pre-paid arrangements
3c - Delayed Luggage

3f - Rental Vehicle Insurance Excess

Rental vehicle agreement showing the excess you are liable for
Receipts for excess payment
Credit card statement showing payment of the excess
Copy of repair quote/account
Copy of rental vehicle accident/incident report
3g - Resumption of Trip
Original trip booking invoice itemising breakdown of costs for
both original and new booking
Original and new itinerary
Copy of return ticket used and unused
Booking conditions that applied to original trip
Cancellation fees that would have applied had the original trip
been cancelled in full
Invoice and receipt for new ticket purchase to
resume journey
Medical or death certificate of relative who caused return to
Australia
3h - Medical and Dental Expenses
General Practitioner/Dentist Medical Certificate (p8)
Original medical/dental receipts

Property Irregularity Report (PIR)

Treating doctors report

Written confirmation from the carrier of when your luggage was

returned to you and compensation paid

Hospital admission & discharge reports where relevant

Original receipts for essential items purchased

Boarding pass & baggage tags from the carrier who caused your
luggage to be delayed
3d - Lost, Stolen or Damaged Luggage & Personal Effects
Proof of ownership of all items
Repair quotes for damaged items
Loss report from police or relevant authority made within 24 hrs
of loss

Letter from dentist with details of emergency treatment provided

Loss of Income (Due to Injury Overseas)
Doctors report detailing period unfit to work
Centrelink advice of payment if you have an entitlement
Written confirmation from your employer of the date you were
scheduled to return to work
Pay slips for the 6 months prior to the departure of your trip (to
allow us to confirm your average pay)

Original receipts for replacement items

Property Irregularity Report (PIR)
Boarding pass & baggage tags from the carrier
ATM, bank, credit card statement or currency conversion slips
showing withdrawal of funds
Proof that IMEI number locked for mobile phones

Need some help?

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