HOLIDAY CANCELLATION CLAIM FORM
 
  
Claimant's Full Name
Address

Holiday Establishment Name and Address

Date Booking Made   Booking Cancelled
Booked Date of Holiday:  From   To
Amount Already Paid to Accommodation Provider £
Amount Owing to Accommodation Provider £
(Please supply supporting accounts)
 
Reason for claim and relationship to claimant

If you have annual travel insurance e.g. as an extension to your Home Insurances or provided with your Credit Card, please advise us of the name, address and Policy number of your insurers:




If cancelled for medical reasons, please have the Medical Certificate completed.
If for any other reason, please supply documentary evidence to support your claim.
D E C L A R A T I O N
I declare to the best of my knowledge that the above particulars, and any additional information, are true.  I authorise that payment, as appropriate, be made directly to the Accommodation Provider and/or myself in respect of the deposit, in full and final settlement of this claim.
Signature of Claimant   Date
 
MEDICAL CERTIFICATE
This Certificate to be furnished at the claimant's expense and to be completed by the usual Doctor of the person requiring medical attention.  In the event of death, please attach a copy of the Death Certificate.
1.   Patient's Name
2.   (a) Are you this patient's usual Doctor?   YES / NO
  (b) If Yes, for how long?
3.   Describe (a) accidental injuries (b) illness of patient 
 
4. Date medical treatment first sought for this condition
5. History of this condition or any relevant condition with dates of treatment.
  If none, please state.
6. If you were treating the patient prior to the holiday was the patient fit
  to travel at the date of booking shown above?  YES / NO
Date  Signature   Qualifications
Address
PLEASE RETURN TO:  
J L Morris (Insurance Brokers) Ltd.
Manor House, 1 Macaulay Road, Broadstone,  BH18 8AS