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SubmitTravelClaimWeb

Claim Form Travel Insurance

Please fill out the form along with the required documents for claim review

Pilih Bahasa/ Choose Language

Select an option

Indonesia
English

Insured/ Claimant Details

Full Name*

Mobile No. (Whatsapp)*

Email*

Insured/ Claimant Address*

Travel & Loss Details

Policy No*

Travel Period*

Date and Time of Loss/ Accident*

Location of Loss/ Accident*

Type of Loss/ Accident*

Select an option

Personal Accident, Medical and Evacuation Repatriation Expenses
Baggage & Personal Belongings, Travel Documents
Trip Curtailment, Deposit Loss/Cancellation
Baggage Delay, Travel Delay, Flight Misconnection
Personal Liability, Household cover, Own Risk of Rent Vehicle, Golfing Equipment
Others (Hijacking, Terrorism)

Description (Chronology) of Loss/ Accident/ Nature of Illness*

Total amount claimed in original currency*

Select

Do you have any other insurance policies that cover the same risk of loss/damage? If yes, please declare*

Select

Insurance Company*

Policy No.*

Insured/ Claimant Bank Account Details

Bank Account Name (Listed in the passbook)*

Account No.*

Bank Name*

Bank Branch*

Mandatory Required Original Documents

General Documents required to proceed your claim (Upload your document)

Original boarding pass, Ticket, or Itinerary*

Passport/KTP/ KITAS/ others insured identity*

Evidence of loss*

Specific Document: Personal Accident, Medical and Evacuation Repatriation Expenses

Medical Report or Death Certificate

Original Invoice and receipt

Identity Card of heirs and Family Card

Medical Report or Death Certificate

Original Invoice and receipt

Identity Card of heirs and Family Card

Check the box below to continue

Vérification du texte Requis

I/ We have read and agree to the Power of Declaration, Authorization & Customers Data Privacy Consent.

I am willing to receive News and Information from AXA Insurance Indonesia.

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SubmitTravelClaimWeb

Claim Form Travel Insurance