Cornerstone

Local Travel Insurance Claim

Name (Surname) *

Name (First Name) *

Policy Number *

Phone No *

Email Address *

Address *

City *

State *

Departure *

Destination

Date of Incident (yyyy-mm-dd) *

Time of Incident *

Where Did the Incident Occur? *

Brief Details of Incident *

Purchase Receipt of Lost Items *

Copy of Travel Ticket *

Any Document From The Airline/Carrier/Transporter Accepting Liability

Estimate Of Claim *

Statement of Authenticity/Truth of Details Given Above (Please Tick Box). *