Colina Insurance Limited

P.O. Box N4728

TRAVEL INSURANCE
Nassau, The Bahamas CLAIM FORM

ONLY COMPLETE THIS FORM IF YOU TEST POSITIVE WITH A COVID-19 PCR TEST WHILE IN THE BAHAMAS
Please complete ALL sections of this form (two pages), sign and date it, and send it to Colina Insurance Limited. This form,
along with the supporting documents, must be received within 90 days of the date of your positive COVID-19 PCR test. A
delay in processing the claim will occur if an incomplete form or unacceptable proof of loss is submitted. Forms can be
returned via:
• E-mail to Travelclaim@colina.com or
• Fax to 242-393-8773

The following documentation must also be submitted where applicable:

• Positive COVID-19 PCR test results;
• Airline ticket, itinerary or boarding pass showing arrival and departure dates and proof of payment;
• Lodging and meal receipts
• Detailed medical bills/invoices; and
• Receipt(s) for payment of medical expenses

SECTION A - General Information

Primary Insured
Title Last Name First Name Middle Initial Maiden Name

Miss
Mrs
Mr
Address
No. / Street City State / Province / Island Zip/Postal Code

Telephone Numbers
Residence Business Cell Fax

Email Address Gender

Male Female

Traveler ID No. Trip ID No.

Date of Positive PCR test Arrival Date Departure Date

Day Month Year Day Month Year Day Month Year

SECTION B - Additional Travellers

Please list any additional travellers in your party with whom you shared accommodations:

Last Name First Name Initial

Did any travellers in your party also have a positive COVID-19 PCR test? Yes No
Please indicate which ones by ticking next to their name above.

Travel Insurance Claim Form • 2021–12–29 Page 1 of 2

 Colina Insurance Limited
P.O. Box N4728
TRAVEL INSURANCE
Nassau, The Bahamas CLAIM FORM
SECTION C - Other Coverage

Do you have any other insurance that may provide benefits for this loss Yes No
If you answered “Yes” to the above, please provide the following:
Name of Insurance Company Policy/Certificate Number Telephone Number & Website

SECTION D - Claim Reimbursement & Assignment Information

If claim is being submitted for a child under the age of 18, please provide the name of a relative to whom payment should be made:
Relative
Title Last Name First Name Middle Initial Relationship

Miss
Mrs
Mr
Address if different from above
No. / Street City State / Province / Island Zip/Postal Code

If benefits are being assigned, please provide the name of the assignee and the dollar amount of benefits being assigned.

Name of Assignee Amount Assigned ($)

SECTION E - Electronic Funds Transfer Authorization

Bank Name Name on Account (Beneficiary)

Bank Address
No. / Street City State / Province / Island Zip/Postal Code

Bank Account Number Account Type ABA Routing Number IBAN SWIFT Code
Savings
Chequing

Are you currently collecting VAT? Yes No If yes, please provide VAT TIN#

SECTION F - Declaration & Authorization

By signing below, I certify that the information stated above is true and correct and authorize Colina Insurance Limited to execute
the Electronic Funds Transfer for reimbursement of benefits payable in accordance with the Schedule of Benefits. I understand and
acknowledge that the benefit payable may be reduced by fees charged by the recipient’s bank.

I hereby certify that the above is a true statement of the travel expenses incurred by me in accordance with the Travel Insurance Program.
I authorize any physician, medical practitioner, hospital, clinic, other medical or medically related facility, the Medical Information Bureau
Inc., or insurance company to give to Colina Insurance Limited, or its legal representative, any and all such information necessary to
evaluate this claims for payment of benefits.
Insured or Authorized Person Date
Print name Signature Day Month Year

Travel Insurance Claim Form • 2021–12–29 Page 2 of 2