TRANSMED INTERNATIONAL : MAKE A CLAIM : MEDICAL EMERGENCY & REPATRIATION INSURANCE FOR HAULAGE TRUCK & LORRY DRIVERS

Policy Number*:
Policy Start Date*:
Policy Holder (Company or Individual)*:
Full Address*:
Claim Contact (Name)*:
Daytime Telephone Number*:
Email Address*:

Driver (Full Name and Title)*:
Date of Birth*:
Class of License*:
Vehicle*:
Registration Number*:
Date of Incident*:
Location*:

Give Details of this Incident*:

IF ILLNESS:
a) the date on which symptoms first became apparent:
b) whether the claimant has suffered the same illness before:
c) and if so, when:

Amount Claimed (£, $, € etc): You may be asked to provide receipts etc.*
Where are the Vehicle and Goods Now?*:

Name of Person Filling out this Form*:

DECLARATION I declare that to the best of my knowledge and belief all the information I have provided in connection with this Claim whether in my own hand or not is true and that any and all Material Facts have been disclosed to the Insurers. Please see the definition of MATERIAL FACTS contained in your Policy. I understand any non-disclosure or misrepresentation of a Material Fact may entitle underwriters to void the insurance and that making a fraudulent claim is a criminal offence.
Please Tick if You've Read and Agreed to the Above Statement: