Sheet1TRAVEL CLAIM FORM(THNG BO TN THT V YU CU BI THNG BO HIM DU LCH)THIS FORM IS ISSUED WITHOUT ADMISSION OF LIABILITY AND IT MUST BE COMPLETED AND RETURNED TO US IMMEDIATELY, WHETHER OR NOT A CLAIM IS MADE(Cng ty Liberty Insurance Limited khng tha nhn bt c trch nhim bi thng no trong thng bo ny, n phi c in y thng tin v gi v cho chng ti ngay khi c th cho d yu cu bi thng c c chp nhn hay khng.)CLAIM NO. (Office use only)Branch (Chi nhnh):Broker/Agent (Mi gii/i l):Address (a ch):INSURED/POLICYHOLDER (NGI C BO HIM)Policy No.:(S Hp ng bo him:)Insurance Period:(Thi hn bo him:)From:(t)To:(n)Name of Insured:(Tn Ngi c Bo Him:)Gender (gii tnh):Occupation (Ngh nghip) :Birthday (nm sinh):Contact Address: (a ch lin lc: )Contact Person & Tel. No.:(Tn ngi lin lc & S in thoi:)Email Address :(a ch Email:)Traveling with companion(s)? (Du lch c ngi i cng?): Yes (c): No (Khng)If Yes, please provide details (Nu c vui lng ghi chi tit):Name(H tn ngi i cng)Birthday(nm sinh)Relationship(Mi quan h)Gender(Gii tnh)Passport / ID Card No(S Passport hoc CMND)Companition is insured by Liberty VN?(C c bo him bi Liberty VN?)Beneficiary name (Tn ngi th hng tin bi thng):Gender (gii tnh):Birthday (nm sinh):Contact Address: (a ch lin lc: )Passport / ID Card No (S Passport hoc CMND) :PARTICULARS OF ACCIDENT/LOSS (THNG TIN V TAI NN/TN THT)Date of Accident/Loss:(Ngy xy ra tai nn/tn tht:)Time of Accident/Loss:(Thi gian xy ra tai nn/tn tht:)Place of Accident/Loss:(a im xy ra tai nn/tn tht:)Brief Description of Accident/Loss:(Xin vui lng m t vn tt v tai nn/tn tht:)(a) Personal accident/Sickness - medical and related expense (Please attach original medical files and cost receipts or death certificate)(a) Tai nn / m au c nhn - Chi ph y t v chi ph lin quan ( ngh nh km bn gc h s bnh n v ha n chi ph y t hoc giy chng t)1. Have you ever suffered the sickness/injury or a similar condition or a recurrance of a previous illness/injury?(Bn tng b tnh trng tng t hoc b ti pht bnh / Thng tn nh vy cha?)Yes (C)No (khng)IF yes, please specify: (Nu c vui lng ghi c th)2. Net amount claimed (S tin yu cu bi thng):USDVND3. Hospital and Doctor's name (Tn bnh vin v bc s iu tr):(b) Cancellation / Curtailment (Please attach documents from carrier / travel agent)(b) Hy chuyn / Ct gim chuyn i ( ngh nh km ti liu xc nhn t hng vn chuyn / i l du lch)Booking time and place(Thi gian v a im t v)Intended departure date(Ngy d kin khi hnh)Date cancelled / curtailed(Ngy hy / ct gim chuyn i)Cause(Nguyn nhn)Remark(Ghi ch)1. Amount paid by you (S tin bn tr):2. Amount recovered from other sources (S tin thu v t ngun khc):3. Amount claimed (S tin yu cu bi thng):(.c ) Luggage and Personal effects (Please furnish police report, original purchase receipts and bills/receipts of repair cost)(.c ) Hnh l v vt dng c nhn ( ngh cung cp bn khai bo cng an, bn gc chng t mua v ha n sa cha)Item / Description(Tn / M t vt dng)Time and place of purchase(Thi gian v ni mua)Original purchase price(Gi mua gc)Cost of repair(Chi ph sa cha)Depreciation for usage(Khu hao hao mn s dng)Claim amount(S tin yu cu bi thng)(d) Travel or fly delay (Please attach letter from airlines/Carrier and boarding pass)(d) Tr chuyn i hoc chuyn bay ( ngh nh km xc nhn ca hng vn chuyn v th ln phng tin vn chuyn)Original travel or flight details (Chi tit chuyn bay d kin)Delayed travel or flight details (Chi tit chuyn bay b tr)Date (Ngy)Date (Ngy)Time (Gi)Time (Gi)Place of departure (Ni khi hnh)Place of departure (Ni khi hnh)Carrier or flight No (S hiu phng tin vn chuyn)Carrier or flight No (S hiu phng tin vn chuyn)Name of carrier or airlines (Tn hng vn chuyn)Name of carrier or airlines (Tn hng vn chuyn)(e) Baggage delay (Please attach boarding pass, baggage irregularity report, baggage acknowledgement slip and any other correspondence from the carrier or airlines)(e) Chm hnh l ( ngh nh km th ln phng tin vn chuyn, bo co hnh l bt thng, bin nhn gi hnh l v cc chng t khc t hng vn chuyn)Travel or flight details (Chi tit chuyn i)Collection of delay baggage (Nhn li hnh l tr)Arrival date (Ngy n)Date (Ngy nhn)Arrival time (Gi n)Time (Gi nhn)Place of arrival (Ni n)Place (Ni nhn)Carrier or flight No (S hiu phng tin vn chuyn)Name of carrier or airlines (Tn hng vn chuyn)OTHER INSURANCE(BO HIM KHC)Is there any other policy(ies) covering the Insured in respect of this accident? (C cc n bo him khc bo him cho Ngi c bo him i vi tai nn ny khng?)Yes(c)No(khng)If Yes, please give details(Nu c xin vui lng cho bit chi tit:)DECLARATION(Cam oan)I/we do solemnly and sincerely declare that the foregoing particulars are true and correct in every detail and I/we agree that if I/we have made or in any further declaration in respect of the said claim shall make any false or fraudulent statements of suppress conceal or falsely state any material fact whatsoever the Policy shall be void and all rights to recover thereunder in respect of past or future claims shall be forfeited.(Ti/chng ti tuyn b rng cac thng tin k khai trn y la ung v xc thc tng chi tit. Ti/chng ti ng y rng nu ti/chng ti khai bao sai s tht hoc la di trong yu cu bi thng hoc cc thng bo b sung v yu cu bi thng , hoc khng thng bo, che du hoc khai sai s tht bt k thng tin quan trong no, Hp ng bao him se bi v hiu va moi quyn li bo him theo Hp ng bao him i vi cac yu cu bi thng trc y hoc sau ny se khng c gi tr.)I/we hereby authorize any hospital physician, other person who has attended or examined me, to furnish upon request to Liberty Viet Nam, or its authorized representative, any or all information with respect to any illness or injury, medical history, consultation, prescriptions or treatment, and copies of all hospital or medical records. A photostatic copy of this authorization shall be considered as effective and valid as the original.(Ti/chng ti bng vn bn ny cho php bnh vin, bc s hoc bt k ai khm cha bnh cho ti, cung cp cho Liberty Vit Nam hoc ngi i din theo y quyn ca Liberty Vit Nam khi c yu cu bt k hoc ton b cc thng tin lin quan n bnh tt hoc thng tn ca ti, v qu trnh cha tr, khm bnh k toa hoc iu tr, cng ton b bn sao ca chng t y t. Bn sao ca giy y quyn ny cng c coi nh c hiu lc v gi tr nh bn chnh.)/ /Date(ngy)Signature of the Insured(Ngi c bo him)

&L&G&R&"Arial,Bold"LIBERTY INSURANCE LIMITED&"Arial,Regular"Kumho Asiana Plaza, 15th fl.39 Le Duan St., District 1Ho Chi Minh City, VietnamTel: (84-8) 38 125 125Fax: (84-8) 38 125 018&L&"Arial,Italic"&7CL-T00-C-001-01-Boooooo

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