Scribd Logo
Upload

Welcome to Scribd!

  • 14 views

    Reliance_Inland_Travel_Claim_Form_C

    Uploaded by

    amdcagst
    V Good

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Reliance_Inland_Travel_Claim_Form_C

    Uploaded by

    amdcagst
    14 views2 pages
    V Good

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    V Good

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    14 views2 pages

    Reliance_Inland_Travel_Claim_Form_C

    Uploaded by

    amdcagst
    V Good

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    You are on page 1of 2

    reliancegeneral.co.

    in
    022 4890 3009 (Paid)
    74004 22200

    Reliance Inland Travel Care Policy Claim No.


    Claim Form C
    *Policy No./Certificate No.
    Name of the common carrier
    Flight No. From: To:
    PNR No.
    Please complete the section relevant to your claim
    Loss of Total Checked in Baggage

    Date: d d m m y y y y Time: hrs Location:


    Number of pieces of baggage checked-in:
    Number of pieces of baggage lost:
    In case of baggage, please specify the following
    Scheduled date of Arrival: Scheduled time of Arrival: : Hrs
    Actual date of Arrival: Actual time of Arrival: : Hrs
    (Please provide the details of expenses related to the loss of the checked baggage in the table given below)

    Trip Delay/Cancellation/Interruption/Missed Connection


    Reason for Trip delay/Cancellation/Interruption
    Death or Unforeseen disease/illness/injury Termination of Employment Inclement Weather Conditions
    Uninhabitable condition of the place of stay abroad due to fire, flood, vandalism, burglary, or natural disaster
    Abduction/Quarantine of the Insured Person Felonious Assault on the Insured Person/Family Member/Traveling Companion
    Terrorist Incident in the place of visit Delay of Common Carrier* Lost or stolen passport, travel
    documents or money.*
    * Not applicable for trip delay

    In case of trip delay and missed connection

    Scheduled date of Arrival: Scheduled time of Arrival: : Hrs

    Actual date of Arrival: Actual time of Arrival: : Hrs

    Number of Hours delayed:

    In case of missed connection

    Date of Departure of Connecting Flight Time:

    In case of trip cancellation/trip interruption

    Date Time: Location

    Whether accommodation & boarding provided by carrier? Yes No


    Detail of Expenses incurred Date Place Cost

    Total
    Less Compensation received from airline

    Net Amount

    An ISO 9001:2015 Certified Company


    RCare Health: Reliance General Insurance, No.1-89/3/B/40 to 42/ks/301, 3rd floor, Krishe Block, Krishe Sapphire, Madhapur, Hyderabad 500081.
    Reliance General Insurance Company Limited. IRDAI Registration No. 103. Registered & Corporate Office: Reliance Centre, South Wing, 4th Floor, Santacruz (East),
    Off. Western Express Highway, Mumbai 400055. Corporate Identity No.U66603MH2000PLC128300. UIN No.: RELTIDP07001V010607. Trade Logo displayed
    above belongs to Anil Dhirubhai Ambani Ventures Private Limited and used by Reliance General Insurance Company Limited under License. . RGI/MCOM/CO/HL-
    06/CF-C/VER. 1.3/170820
    * In case of Delay, please provide details of purchases made

    * In case of Loss, please provide details of items lost

    Alternative Employee or Resumption of Assignment Expenses

    Date of loss:
    Nature of loss:
    Cause of loss:
    a. Traveling expense towards deployed person
    b. Return Travel expenditure towards Insured/Insured Person

    Proposer's Bank Details

    Name of the Bank Account Holder Mr. Mrs. Ms.


    Bank Account No.: Account: Saving Current
    Name of the Bank
    Branch
    MICR Code (9 digit MICR code number of the bank and branch appearing on the cheque issued by the bank)
    IFSC Code (11 character code appearing on your cheque leaf)
    I understand that any refund due on the premium payment / any payment / claims to be directly credited to my aforesaid Bank Account.*
    *As per IRDAI, its mandatory that all payments made to the insured are only through electronic mode.

    * Mandatory details to be filled

    Please courier documents to the below address:


    Rcare Health: Reliance General Insurance, No.1-89/3/B/40 to 42/ks/301, 3rd floor, Krishe Block, Krishe Sapphire, Madhapur, Hyderabad 500081.
    Email: rgicl.rcarehealth@relianceada.com This claim form shall be applicable for Reliance Inland Travel Care Policy
    UIN of Reliance Inland Travel Care Policy: UIN No.: RELTIDP07001V010607

    You might also like