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                                                                  StudentCare Claim Form
                                   Post or fax to: InterGlobal Limited, PO Box 8672, Symonds Street, Auckland, New Zealand
                                                        Facsimile 64-9-309 4119. Telephone 64-9-309 2119
IMPORTANT NOTE: Please return this form as soon as possible. For prompt payment you must attach the following: 1. Police or Local Authority/Airline/Carrier reports.
2. Original doctor's certificates and/or receipts. 3. Original purchase receipts for old and new items and replacement quotes. 4. For Loss of Deposits claims ­ a copy
of your original itinerary from your travel agent. 5. If none of these are available please state why:


                                     Sections of this policy are subject to an excess and these will be deducted from the amount of the claim.
Member N0:                                                                                               Period of Cover from:                                  /             /                 to:          /              /
                                                                                                                                                           DD            MM         YY                  DD        MM            YY

First Name:                                                                                              Surname:

Postal Address:

Date arrived in New Zealand:               DD
                                                /   MM
                                                         /   YY
                                                                                                         Nationality:

Attending School:                                                                                        Date of birth:                  DD
                                                                                                                                               /      MM
                                                                                                                                                                /   YY
                                                                                                                                                                                         Sex:         Male         Female

Home phone: (                 )                     Mobile: (           )                                Home fax: (                       )                                             E-mail:

Important: Were any special conditions, terms or endorsements applied to this policy?                                      Yes            No If `Yes' please state:

Please complete this section if your claim relates to any of the following: Doctor or Specialist Fees ­ Public Hospital Services ­ Private Hospital Services ­ Pharmaceutical
­ Ambulance Services ­ Physiotherapy ­ Rehabilitation ­ Emergency Dental Treatment ­ Emergency Maternity Services ­ Medical Evacuation ­ Repatriation ­ Funeral Expenses ­
Family Assistance/Travel Expenses ­ Medical/Dental Emergency

Name of the person treated:                                                                                                                                                              Date of birth:                 /            /
                                                                                                                                                                                                                   DD           MM       YY


Date:       DD
                 /   MM
                          /   YY
                                                         Time:                                morning                afternoon                 night                          Country:

Please advise the reason you visited the doctor. What was wrong with you?




What treatment did you receive and what was the final diagnosis:                 (this question must be answered before the claim can be processed)




Were you suffering or receiving treatment for this illness before purchasing this Insurance?                                       Yes             No If YES, when and which type of treatment had you
received?




Did you contact First Assistance for this claim?                  Yes       No

Name and address of your usual doctor:

                                                                                                         Doctors phone: (                             )

Are these expenses recoverable from any other Medical Plan or Insurance Policy?                                   Yes           No

If YES, declare the name and address of the Medical Plan or Insurer:

REIMBURSEMENT: How do you wish payment of your claim to be made?                             Cheque                                                                                                              (please state currency)

or      Bank account - Bank:                                                                             Branch name and country:

         Account number:                                                                                 Account holder's name:

or      Credit card - Card number:                                                                                                    Expiry:                                                   Card Type:

        Cardholders name:

         Type of treatment -­ complete the appropriate                           Have you paid this account                                                         Date(s)                                        Amount claimed
      sections being claimed and circle relevant treatment
Doctor or Specialist Fees                                                                        Yes / No
Public/Private Hospital Services                                                                 Yes / No
Pharmaceutical/Ambulance                                                                         Yes / No
Physiotherapy/Rehabilitation                                                                     Yes / No
Emergency Dental Treatment/Emergency Maternity Services                                          Yes / No
Medical Evacuation/Repatriation                                                                  Yes / No
Funeral Expenses/Family Assistance/Travel Expenses                                               Yes / No
Medical/Dental Emergency                                                                         Yes / No
Important: You must provide invoices and receipts to support your claim AND you must sign this declaration before sending to InterGlobal Limited.
            InterGlobal Limited is not liable for any bank charges incurred in settling your claim.
Declaration: Please read and sign. 1. I declare that all the above information is true. 2. I agree that if I have made any false statement, or fraudulent claim
or suppress or conceal any information that this policy will be invalid and all rights of recovery will be forfeited. 3. I declare that I do or I do not (please
tick applicable) have any claim with any other insurance company covering this loss. 4. I declare that I have not had any previous claim declined. 5. I authorise
InterGlobal Limited to obtain any medical or other information from any other source, doctor or specialist that will assist in the process of this claim.
6. I agree to provide the Insurer or its' Representative any relevant information regarding current or past claims and to the Insurer or its' Representative releasing
claims information to any other party.
                                                                                                                                                      DD            MM
Signed:                                                                                                                           Dated:                        /             /YY
                                                                                                                                                      DD             MM        YY


Name of Person who has completed this form:
            Please complete this section for: Personal Belongings ­ Advance Payments/Loss of Tuition or Study Fees ­
  Cancellation and Additional Expenses ­ Personal Liability ­ Accidental Death/Disability ­ Loss of Luggage and Personal Effects
                 ­ Delayed Luggage ­ Loss of Deposits and/or Curtailment ­ Travel Delay ­ Missed Connections
Please complete the "REIMBURSEMENT" section on the previous page.
Personal Belongings: Delayed Luggage: Loss of Luggage and Personal Effects
Date of loss:         /        /                                                                       Time:                                                morning     afternoon     night
                 DD       MM       YY

City:                                                                                                  Country:
Please describe how the loss happened and/or how long you were deprived of your luggage:


Reported to the Authorities in:                                                                                                                        (Attach Authorities' report)
Please state what you did to recover or minimise the loss:


Did you receive any compensation from the carrier?                      Yes      No                    (Please send a written confirmation from the carrier)
Did the articles belong to you?          Yes    No
If NO, please explain:
Are the above articles covered under any other Policy?                    Yes         No
If YES, please state the name and address of the other Insurance Company:


Have you since recovered any of these articles?              Yes          No


 Description of the articles owned/bought                                                                           Date of Purchase              Price and Currency             Replacement Price




                                                                                                                                             Total: $

Personal Liability: Accidental Death/Disability
The amount of your claim:
Please state briefly what happened:
Please state the names of the third parties involved:
You may be required to complete a more detailed claim form.

Advance Payments/Loss of Tuition or Study Fees: Cancellation and Additional Expenses: Loss of Deposit and/or Curtailment
The amount of your claim:
The reason why your trip was cancelled or curtailed:
Loss of Deposits ­ Cancellation Date:          DD
                                                    /   MM
                                                              /    YY
                                                                                or Curtailment Date:       DD
                                                                                                                /    MM
                                                                                                                          / YY
Did you hold a return ticket?           Yes    No
Was the curtailment due to a sudden illness or accident of a family member? or travelling companion?                                   Yes        No
If YES, please state the relationship:                                                                                             (in event of death, please include the death certificate)
You must include a breakdown of the cancellation fees from your travel agent. If you were curtailed we need to know the costs of the unused portion of your
travel costs together with a breakdown of cancellation fees and the extra travel costs incurred for your return to your Country of Study or Origin.

Travel Delay: Missed Connection
The amount of your claim:                                                                              (Attach all receipts)
· For Travel Delay please advise how long and the reason for the travel delay.
· For Missed Connection please explain the reason for the missed connection.
Details and dates of loss:

Declaration: Please read and sign. 1. I declare that all the above information is true. 2. I agree that if I have made any false
statement, or fraudulent claim or suppress or conceal any information that this policy will be invalid and all rights of recovery
will be forfeited. 3. I declare that I do or I do not (please tick applicable) have any claim with any other insurance company
covering this loss. 4. I declare that I have not had any previous claim declined. 5. I authorise InterGlobal Limited to obtain any
medical or other information from any other source, doctor or specialist that will assist in the process of this claim. 6. I agree
to provide the Insurer or its' Representative any relevant information regarding current or past claims and to the Insurer or its'
Representative releasing claims information to any other party.

Signed:                                                                                                                   Dated:         /          /
                                                                                                                                    DD       MM        YY



Name of Person who has completed this form:

Additional Claims Forms can be obtained from our website: www.studentcare.biz


                                                                                                                                                                                                PROCLAIM IGL.DC.515 12/05