MAPFRE|INSURANCE® – Trip Interruption Claims Form
TI012015
MAPFRE|INSURANCE®
Claim Form
c/o InsureandGo USA
7300 Corporate Center Drive Suite 601
Miami, FL 33126
Date:
Claim No.:
Trip Interruption
Name of Insured
Home Address
State
City
Zip
Home Telephone
Cell Phone
Mailing Address, if different from Home Address:
Street Address
State
City
Zip
Plan Information/ Trip Information
Policy #
Departure Date
Original Destination
Date of Initial
Deposit/Payment
Traveling Companions (Please indicate name and relationship to you)
1.
6.
2.
7.
3.
8.
4.
9.
5.
10.
MAPFRE|INSURANCE® – Trip Interruption Claims Form
TI012015
Please Complete The Section Below.
Documents You Need to Send Us – SEND DOCUMENTS BUT KEEP COPIES FOR YOUR RECORDS
Original evidence to show your dates of outward and return travel, (e.g. booking invoice, travel tickets, itinerary
etc. and a full breakdown of the total trip cost).
All unused and used travel tickets, itineraries etc.
Original evidence of all additional travel expenses.
If the trip interruption is due to a medical condition, including death, a medical affidavit should be completed
by the primary physician of the individual whose condition has caused the submission of this claim.
If the trip interruption was due to injury or illness of a person while en route; please provide written
confirmation from the local treating physician to confirm the medical necessity of the interruption.
If trip interruption is due to a death, we require a certified copy of the death certificate. In addition, if the
deceased was an insured person, we require a copy of the Letters of Administration issued in respect of the
deceased's estate.
If this claim is being submitted as a result of an injury please provide a full description of the incident leading
to the injury, if a third party was involved please provide their details and those of their insurer if available.
If the trip interruption is for a reason other than those detailed in points 3 and 4 please forward independent
written evidence of the incident or circumstances that have resulted in the submission of the claim.
Proof of payment for the trip (e.g. credit card statement, cancelled check, common carrier and travel supplier
receipts).
Statement from common carrier and travel supplier indicating if any refund, reimbursement, credit, and/or
voucher was issued. If no refund, reimbursement, credit, or voucher was issued, a Copy of the Cancellation
terms and conditions must be provided to verify you are not entitled to reimbursement or credits from any
other source.
Please answer ALL questions below
Dates of scheduled return and actual return
Scheduled
return date
No. of days
booked
Actual
return date
No. of days
unused
If your trip interruption was due to a person who was not travelling with you, please state their name and
relationship to you
Name
Relationship
Was any attempt made to revalidate
or use your original tickets?
YES
NO
If answer is YES, were you successful
in your attempts?
YES
NO
If NO for either question
above, then please
provide an explanation as
to why no attempt was
made to revalidate your
tickets (continue on
separate sheet if
necessary):
MAPFRE|INSURANCE® – Trip Interruption Claims Form
TI012015
Names and ages of all travelers affected by the trip’s interruption
#1
Name
Date of Birth
#2
Name
Date of Birth
#3
Name
Date of Birth
#4
Name
Date of Birth
#5
Name
Date of Birth
#6
Name
Date of Birth
#7
Name
Date of Birth
#8
Name
Date of Birth
#9
Name
Date of Birth
#10
Name
Date of Birth
Please detail the
reasons for trip
interruption
(continue on a
separate sheet if
necessary)
List of additional and unused prepaid expenses (continue on a separate sheet if necessary)
Receipt
No.
Date
Description of item
Currency
Amount
Paid
Y/N
Total
Claimed
MAPFRE|INSURANCE® – Trip Interruption Claims Form
TI012015
Other Insurance
a. Do you (or anyone else claiming) have any other insurance which may cover
this trip? ( i.e. Travel Insurance with your bank/credit card account, tour
operator/travel agent or home owners insurance, etc.)
b. If yes, please supply the following details:
Has a claim been submitted to any other company for this incident?
Please provide details:
Please select the method of payment for the trip. Note – more than one selection can be made so please select all
that apply.
Trip Payment Methods
Cash
Check
Credit/Debit Card
Reward Points/Air Miles
If a Credit/Debit card was used to pay all or some of the trip cost, please state:
Previous claims
Have you made any previous claims under this type of insurance?
If yes please give details:
Were you aware of any reason why the trip might have needed to be cut short at the
time of policy purchase of the policy or on the date of travel?
YES
NO
If yes, please provide additional information:
YES
NO
Company name
Policy
Number
Company
Address
State
City
Zip
YES
NO
Name of issuing bank and type (Visa, MC, AMEX)
Card account number
YES
NO
MAPFRE|INSURANCE® – Trip Interruption Claims Form
TI012015
STATE FRAUD WARNING LANGUAGE
Alabama
"Any person who knowingly presents a false or fraudulent
claim for payment of a loss or benefit or who knowingly
presents false information in an application for insurance
is guilty of a crime and may be subject to restitution,
fines, or confinement in prison, or any combination
thereof."
Alaska
"A person who knowingly and with intent to injure,
defraud, or deceive an insurance company files a claim
containing false, incomplete, or misleading information
may be prosecuted under state law."
Arizona
"For your protection Arizona law requires the following
statement to appear on this form. Any person who
knowingly presents a false or fraudulent claim for
payment of a loss is subject to criminal and civil
penalties."
Arkansas
"Any person who knowingly presents a false or fraudulent
claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance
is guilty of a crime and may be subject to fines and
confinement in prison."
California
IN GENERAL: "For your protection California law requires
the following to appear on this form: Any person who
knowingly presents false or fraudulent claim for the
payment of a loss is guilty of a crime and may be subject
to fines and confinement in state prison."
Colorado
"It is unlawful to knowingly provide false, incomplete, or
misleading facts or information to an insurance company
for the purpose of defrauding or attempting to defraud
the company. Penalties may include imprisonment, fines,
denial of insurance and civil damages. Any insurance
company or agent of an insurance company who
knowingly provides false, incomplete, or misleading facts
or information to a policyholder or claimant for the
purpose of defrauding or attempting to defraud the
policyholder or claimant with regard to a settlement or
award payable for insurance proceeds shall be reported
to the Colorado Division of Insurance within the
Department of Regulatory Agencies."
Delaware
"Any person who knowingly, and with intent to injure,
defraud or deceive any insurer, files a statement of claim
containing any false, incomplete or misleading
information is guilty of a felony."
District of Columbia
"WARNING: It is a crime to provide false or misleading
information to an insurer for the purpose of defrauding
the insurer or any other person. Penalties include
imprisonment and/or fines. In addition, an insurer may
deny insurance benefits if false information materially
related to a claim was provided by the applicant." [DC
Code]
Florida
"Any person who knowingly and with intent to injure,
defraud, or deceive any insurer files a statement of claim
containing any false, incomplete, or misleading
information is guilty of a felony of the third degree."
Idaho
"Any person who knowingly, and with intent to defraud
or deceive any insurance company, files a statement
containing any false, incomplete or misleading
information is guilty of a felony."
Indiana
"A person who knowingly and with intent to defraud an
insurer files a statement of claim containing any false,
incomplete, or misleading information commits a felony."
Kentucky
"Any person who knowingly and with intent to defraud
any insurance company or other person files a statement
of claim containing any materially false information or
conceals, for the purpose of misleading, information
concerning any fact material thereto commits a
fraudulent insurance act, which is a crime."
Louisiana
"Any person who knowingly presents a false or fraudulent
claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance
is guilty of a crime and may be subject to fines and
confinement in prison."
MAPFRE|INSURANCE® – Trip Interruption Claims Form
TI012015
Maine
"It is a crime to knowingly provide false, incomplete or
misleading information to an insurance company for the
purpose of defrauding the company. Penalties may
include imprisonment, fines or denial of insurance
benefits."
Maryland
"Any person who knowingly or willfully presents a false or
fraudulent claim for payment of a loss or benefit or who
knowingly or willfully presents false information in an
application for insurance is guilty of a crime and may be
subject to fines and confinement in prison."
Minnesota
"A person who files a claim with intent to defraud or
helps commit a fraud against an insurer is guilty of a
crime."
New Hampshire
"Any person who, with a purpose to injure, defraud or
deceive any insurance company, files a statement of
claim containing any false, incomplete or misleading
information is subject to prosecution and punishment for
insurance fraud as provided in RSA 638:20."
New Jersey
"Any person who knowingly files a statement of claim
containing any false or misleading information is subject
to criminal and civil penalties."
New Mexico
"Any person who knowingly presents a false or fraudulent
claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance
is guilty of a crime and may be subject to civil fines and
criminal penalties."
Ohio
"Any person who, with intent to defraud or knowing that
he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive
statement is guilty of insurance fraud."
Oklahoma
"WARNING: Any person who knowingly, and with intent
to injure, defraud or deceive any insurer, makes any claim
for the proceeds of an insurance policy containing any
false, incomplete or misleading information is guilty of a
felony."
Pennsylvania
"Any person who knowingly and with intent to defraud
any insurance company or other person files an
application for insurance or statement of claim containing
any materially false information or conceals for the
purpose of misleading, information concerning any fact
material thereto commits a fraudulent insurance act,
which is a crime and subjects such person to criminal and
civil penalties."
Rhode Island
"Any person who knowingly presents a false or fraudulent
claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance
is guilty of a of a crime and may be subject to fines and
confinement in prison."
Tennessee
"It is a crime to knowingly provide false, incomplete or
misleading information to an insurance company for the
purpose of defrauding the company. Penalties include
imprisonment, fines and denial of insurance benefits."
Texas
"Any person who knowingly presents a false or fraudulent
claim for the payment of a loss is guilty of a crime and
may be subject to fines and confinement in state prison."
Virginia
"It is a crime to knowingly provide false, incomplete or
misleading information to an insurance company for the
purpose of defrauding the company. Penalties include
imprisonment, fines and denial of insurance benefits."
Washington
"It is a crime to knowingly provide false, incomplete or
misleading information to an insurance company for the
purpose of defrauding the company. Penalties include
imprisonment, fines and denial of insurance benefits."
West Virginia
"Any person who knowingly presents a false or fraudulent
claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance
is guilty of a crime and may be subject to fines and
confinement in prison."
MAPFRE|INSURANCE® – Trip Interruption Claims Form
TI012015
New York
"Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading,
information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be
subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation."
Insured Signature:
Date:
AUTHORIZATION
The undersigned represents and warrants information or documents provided to
MAPFRE|INSURANCE®
by the undersigned prior to and after
the date of the application for insurance and the facts and other matters contained in the foregoing are true and accurate to the best of the
undersigned’s knowledge and belief.
Signature of Claimant 1:
Date:
Signature of Claimant 2:
Date:
Signature of Claimant 3:
Date:
Signature of Claimant 4:
Date:
MAPFRE|INSURANCE® – Trip Interruption Claims Form
TI012015
Each person filing a claim must sign and date below.
Signature of Claimant
Date
Signature of Claimant
Date
Signature of Claimant
Date
Signature of Claimant
Date
Return the complete form via email, fax, or mail to:
E-mail:
mapfretravelclaims@insureandgousa.com
Fax:
(877)570-9801
Mail:
MAPFRE|INSURANCE® c/o InsureandGo USA
7300 Corporate Center Dr. Suite 601
Miami, FL 33126
For any questions please contact the below phone number.
Monday – Friday 9:00 AM to 5:00 PM EST
Phone:
(888)838-0921
Insurance underwritten by American Commerce Insurance Company Plan
administered by Insure & Go Insurance Services USA, Corp