Bajaj Allianz Overseas Travel Insurance Claim Form Completed Form Examples and Samples
View real filled examples of the Bajaj Allianz Overseas Travel Insurance Claim Form — including medical emergencies, trip cancellations, baggage loss, and more. See sample forms with complete field-by-field data to understand exactly how to fill your claim correctly and get reimbursed faster.
Bajaj Allianz Overseas Travel Insurance Claim Form Example – Medical Emergency Abroad
How this form was filled:
Our AI extracted all relevant claim details from a travel assistance coordinator's incident report and automatically filled the Bajaj Allianz Overseas Travel Insurance Claim Form. The AI intelligently identified the policyholder, claimant, trip details, nature of illness, hospital information, and expense amounts — all from a single unstructured narrative document — and mapped them to the correct form fields.
Source document used: Travel Assistance Coordinator's Incident Report
INCIDENT REPORT — OVERSEAS TRAVEL ASSISTANCE Coordinator: Priya Nambiar | Case Reference: OTA-2025-084712 Date of Report: 14 November 2025 This report documents the medical emergency involving our insured traveler, Mr. Rajesh Kumar Sharma, a 47-year-old Indian national residing at 14B, Lotus Gardens Apartment, Sector 62, Noida, Uttar Pradesh – 201309. His contact number on file is +91-9876543210 and his email is [email protected]. Mr. Sharma holds a Bajaj Allianz overseas travel insurance policy, Policy No. OT-2025-7743882, under the Gold Plan, with a sum insured of USD 250,000. The policy was issued on 3 September 2025 and is valid through 3 March 2026. Mr. Sharma departed from Indira Gandhi International Airport, New Delhi on 28 October 2025 and was scheduled to return on 20 November 2025. He was traveling to the United States for a business conference in Chicago, Illinois. His passport number is P8834521, issued on 12 January 2022, valid until 11 January 2032. On 5 November 2025, Mr. Sharma experienced sudden severe chest pain and shortness of breath at his hotel. He was rushed by ambulance to Northwestern Memorial Hospital, 251 E. Huron St, Chicago, IL 60611. He was admitted the same day and diagnosed with Acute Myocardial Infarction (heart attack). He underwent emergency coronary angioplasty and was hospitalized for six days, being discharged on 11 November 2025. The treating physician was Dr. Michael O'Brien, MD (Cardiologist). Total medical expenses incurred are as follows: Hospital room and board — USD 18,400; Surgical procedure (angioplasty) — USD 32,750; Physician fees — USD 4,200; Diagnostic tests and lab work — USD 3,650; Ambulance charges — USD 850. Total claimed amount: USD 59,850. All original invoices and discharge summary have been collected. Mr. Sharma's travel ticket was originally booked with United Airlines, flight UA-289. Due to the hospitalization, his return journey had to be rescheduled, incurring an additional rebooking fee of USD 420. He also requests reimbursement for the unused hotel nights from 5–11 November 2025 amounting to USD 1,260. The insured has confirmed he had no pre-existing cardiac condition on record at the time of policy issuance. He does not hold any other medical insurance policy covering this trip. His nominee is Mrs. Sunita Sharma (spouse), residing at the same address. Bank details for reimbursement: Account Name — Rajesh Kumar Sharma, Bank — HDFC Bank, Branch — Sector 18 Noida, Account No. 50100234567890, IFSC Code — HDFC0001234. All supporting documents have been forwarded to the claims team. This case is flagged as high priority given the claim value.
Information used to fill out the document:
- Insured Name & Age: Rajesh Kumar Sharma, 47 years old
- Policy Number & Plan: OT-2025-7743882, Gold Plan, valid 3 Sep 2025 – 3 Mar 2026
- Travel Dates & Destination: 28 Oct 2025 – 20 Nov 2025, United States (Chicago, IL)
- Medical Emergency: Acute Myocardial Infarction on 5 Nov 2025; hospitalized at Northwestern Memorial Hospital, Chicago; discharged 11 Nov 2025
- Total Claimed Amount: USD 59,850 (hospital, surgery, physician, diagnostics, ambulance) + USD 420 rebooking + USD 1,260 unused hotel
- Passport Number: P8834521
- Bank Details for Reimbursement: HDFC Bank, A/C No. 50100234567890, IFSC HDFC0001234
- Contact Details & Address: 14B Lotus Gardens Apartment, Sector 62, Noida, UP – 201309; +91-9876543210
What this filled form sample shows:
- Extracted full insured name, age, and address from a dense narrative incident report
- Identified and mapped policy number, plan type, and validity dates mentioned mid-paragraph
- Parsed travel dates, destination country, and departure airport from conversational prose
- Correctly categorized itemized medical expenses (hospital, surgery, physician, diagnostics, ambulance) into separate claim fields
- Extracted hospital name, treating doctor, diagnosis, admission and discharge dates from the incident narrative
- Mapped bank account and IFSC details for reimbursement from a closing paragraph
- Recognized additional claims (rebooking fee and unused hotel nights) as separate reimbursable items
Form specifications and details:
| Form Name: | Bajaj Allianz Overseas Travel Insurance Claim Form |
| Use Case: | Medical emergency hospitalization abroad (heart attack in Chicago, USA) |
| Source Document: | Travel Assistance Coordinator's Incident Report |
| Claim Type: | Medical Expenses + Trip Interruption |
| Total Claim Value: | USD 61,530 |
| Insured Nationality: | Indian |
| Destination Country: | United States of America |
| Categories: | insurance forms, insurance claim forms, VA claim forms |
| Created: | March 10, 2026 05:51 AM |