Claim ID: 7168503 Claim Type: TRC Plan Number: F560S

From: Trip Mate, Inc.*

PO BOX 527,
Hazelwood, MO 63042

In CA & UT, dba Trip Mate Insurance Agency

844-777-6856 (Toll-Free) Fax: * E-mail: [email protected]

To: Nursen Turkmen

310 DiamondBack Way
Algonquin IL, 60102

TRAVEL CLAIM FORMS ENCLOSED

Enclosed are the claim forms for the claims you have reported. Please
review each form and complete any information that may be missing.

After completion, sign each form where indicated and return with all
documentation (see instruction page).

You may review the status of your claim online at tripmate.com

by entering your Name, Plan Number and the Claim ID listed above.
Claim ID: 7168503 Claim Type: TRC Plan Number: F560S

Trip Cancellation Claim Form

HOW TO COMPLETE YOUR CLAIM FORM
Read the claim form carefully, answer all questions as completely as you can and provide all required documentation.
Please be sure to sign where indicated. Following are some important guidelines for completion of the form:
The information requested under “Trip Information” will help us confirm your purchase of the plan. Check your travel
documents to ensure that the information on your form is correct.
The "Information About Your Cancellation" section will give us details regarding your trip cancellation. After completing
this section, you need to complete only the part that applies to your circumstances.
• If you are seeking reimbursement due to your sickness or injury, you will need to complete Page #2.
• If you are seeking reimbursement due to the sickness, injury or death of a family member, traveling companion,
or business partner, you will need to complete Page #2.
• If your trip cancellation is due to your sickness or injury, or to the sickness, injury or death of a traveling companion,
family member, or business partner, the "Authorization for Release of Information" must be signed by the
patient and the "Attending Physician’s Statement” must be completed by the treating physician. Please ask
the physician to answer every question and sign the form. If your trip cancellation is due to a death, include a
certified copy of the death certificate.

REQUIRED DOCUMENTATION:
Payment Information - a copy of your trip itinerary and copies of all invoices, credit card statements and/or
canceled checks evidencing your payment for the trip.
Refund Information - original unused non-refundable tickets; copies of invoices, credit card statements or other
written documentation substantiating the non-refundable costs for your trip (retain originals for your records);
and a copy of the travel supplier's literature that details the cancellation terms and conditions (i.e. penalties
assessed when a trip is canceled). All refundable airline tickets should be sent to the issuing party for the
appropriate refund. Submitting refundable airline tickets to our office may delay your claim.
Additional Expenses - any documentation of expenses for which you are requesting reimbursement, such as:
tickets, receipts, and bills (retain originals for your records).
Cause of Your Trip Cancellation - any documentation substantiating the reason you canceled your trip (retain
originals for your records).
Before returning your claim form, please review the form to make sure all of the information provided is accurate and
complete and that all required documentation is included. Should you have any questions concerning the completion
of this form, please contact our Customer Service Department at the toll-free number below.

Failure to submit the required documentation listed above will delay the processing of your claim.

Trip Mate, Inc.* PO BOX 527, , Hazelwood, MO 63042

844-777-6856 (Toll-Free) Fax: * E-mail: [email protected]

In CA & UT, dba Trip Mate Insurance Agency

TRC-R-02-14
 Claim ID: 7168503 Claim Type: TRC Plan Number: F560S

Trip Cancellation Claim Form

TRAVELER INFORMATION
Gender Date of Birth
Nursen Yilmaz Turkmen
Name 1 _____________________________________________________________ M F X 6 / ___
___ 1 / 1969
___
Prefix First Middle Last Suffix

310 DiamondBack Way

Mailing Address _______________________________________________________ Daytime Telephone # ( 224 ) _____
805 __________
3580
Street Address

Algonquin IL USA 60102

____________________________________________________________________ Evening Telephone # ( 224 ) _____
805 __________
3580
City State/Province Country Postal Code

Preferred Contact Number X Day X Evening

Below, please enter the Name, Gender, Date of Birth and Relationship to Name
1 of other persons in the household who have a claim. Gender Date of Birth Relation to Name 1

Name 2 _____________________________________________________________ M F ___ / ___ / ___ ______________

Prefix First Middle Last Suffix

Name 3 _____________________________________________________________ M F ___ / ___ / ___ ______________

Prefix First Middle Last Suffix

Name 4 _____________________________________________________________ M F ___ / ___ / ___ ______________

Prefix First Middle Last Suffix

TRIP INFORMATION
Attach a copy of the front and back of your canceled check or a copy of
6 / ___
Date You Purchased Protection Plan ___ 1 / 2022
___ your credit card statement showing your protection plan purchase.
GroupCollect, LLC
Name of Tour Operator/Cruise Line/Travel Agency_____________________________________________ Booking/Invoice #______________
United States of America
Tour/Cruise Name and Number ________________________ Primary Trip Destination(s) __________________________________________
3 / ___
Scheduled Trip Information: Scheduled Trip Departure Date ___ 23 / 2023
___ 3 / ___
Scheduled Trip Return Date ___ 29 / ___
2023

Algonquin
Trip Departure City ____________________________ Algonquin
Trip Return City ____________________________
6 / ___
Date of Initial Deposit for Trip ___ 1 / 2022
___ 2 / ___
Date of Final Payment for Trip ___ 3 / 2023
___

Did you book through a travel agent/agency? Yes X No If yes, Agency Name ____________________________________________

Agent Name ___________________________ Telephone No. ( ) _____ __________ E-mail Address _________________________

Is there any other insurance or protection plan covering this trip? Yes X No If yes, Policy or Plan No. ____________________

Name of other insurer__________________________________ Telephone No. ( ) _____ __________ Claim No. _________________

INFORMATION ABOUT YOUR CANCELLATION

8 / ___
Date of Trip Cancellation ___ 24 / ___ 200.00
2022 Amount Paid for Trip $ __________ 200.00
Refund Due $ __________ Amount Being Claimed $ __________

Your Cancellation is the result of: Sickness Injury Death of one of the following:
a Claimant listed above
a traveling family member not listed above
a non-traveling family member or Business Partner
an unrelated traveling companion
X Circumstances other than Sickness, Injury or Death (Describe reason(s) below)
Do not want my child going on the trip far away alone.

TRC-USA- 02-14
844-777-6856 (Toll-Free) Fax: * E-mail: [email protected] Page 1 of 5
Claim ID: 7168503 Claim Type: TRC Plan Number: F560S
If cancellation is the result of sickness, injury or death complete the following additional information:

Name of sick, injured or deceased person _______________________________________ Relationship to You __________________________

If sickness or injury: Date sickness/injury began _____/_____/_____ Date sickness/injury ended _____/_____/_____
If death: Date of death _____/_____/_____ (Include cerified copy of death certificate, funeral notices, obitituaries, etc.)
Nature of sickness, injury or cause of death (provide details about your sickness or describe the accident / injury, including date and place).

If cancellation is due to sickness, injury or death, include the signed Authorization for Release of Information and completed
Attending Physician's Statement.

Any prior treatment or consultation for this sickness / injury? Yes No Date of first treatment _____/_____/_____

Was sickness or injury the sole cause of the trip cancellation? Yes No If No, explain below

INFORMATION ABOUT CARE PROVIDERS

Contact information for the primary care physician:
___________________________________________________________________________________________________ ( ) _____ _______
Physician Name Street Address City, State//Province, Country, Postal Code Telephone #

Contact information for any other physicians or medical suppliers from whom treatment was received:

___________________________________________________________________________________________________ ( ) _____ _______

Name Street Address City, State//Province, Country, Postal Code Telephone #

___________________________________________________________________________________________________ ( ) _____ _______

Name Street Address City, State//Province, Country, Postal Code Telephone #

___________________________________________________________________________________________________ ( ) _____ _______

Name Street Address City, State//Province, Country, Postal Code Telephone #

If hospitalized, contact information for hospital(s) and dates confined:

___________________________________________________________________________________________________ ( ) _____ _______

Hospital Name Street Address City, State//Province, Country, Postal Code Telephone #

Date Hospitalization Began _____/_____/_____ Date Hospitalization Ended _____/_____/_____

___________________________________________________________________________________________________ ( ) _____ _______
Hospital Name Street Address City, State//Province, Country, Postal Code Telephone #

Date Hospitalization Began _____/_____/_____ Date Hospitalization Ended _____/_____/_____

___________________________________________________________________________________________________ ( ) _____ _______

Hospital Name Street Address City, State//Province, Country, Postal Code Telephone #

Date Hospitalization Began _____/_____/_____ Date Hospitalization Ended _____/_____/_____

If hospitalized, include a photocopy of the portion of the hospital bill that shows admission and discharge dates.

Trip Mate, Inc.*

PO BOX 527,
Nursen Turkmen
Hazelwood, MO 63042
310 DiamondBack Way
Algonquin IL, 60102 In CA & UT, dba Trip Mate Insurance Agency
844-777-6856 (Toll-Free) Fax: * E-mail: [email protected]
Page 2 of 5
 Claim ID: 7168503 Claim Type: TRC Plan Number: F560S

Important Information (Please read and sign)

Fraud Warning: Any person who, with the intent to defraud or knowingly facilitates a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement, or conceals information for the purpose of misleading may be
guilty of insurance fraud and subject to criminal and/or civil penalties.

To determine eligibility for claim benefits, claim payment amounts, and identification and prevention of potential fraudulent activity,
the insurance company(ies) underwriting your policy, or its representatives, may disclose the claims information submitted to the
insurance company(ies), or its representatives, to any insurance support organization or fraud information clearinghouse utilized by
the insurance company(ies), or its representatives.

** ATTENTION: IF YOU ARE CLAIMING AIRLINE TICKETS, PLEASE COMPLETE THE BELOW. **

Your airline tickets may have value for up to one year from the original scheduled travel date. Please indicate below whether you
will be exchanging your ticket for another trip. Please note: Your signature on this agreement is not a guarantee of payment. All
final claim determinations are subject to eligibility and the terms of the policy.

___ I (We) will not be using our airline ticket(s). (Please include a copy of your electronic ticket confirmation(s) which includes your
ticket number(s).)

___ I (We) will be exchanging our airline ticket(s) for future travel. (Please submit documentation of the cost you incurred or will
incur to exchange your ticket(s).)

_X_ I (We) did not purchase airline ticket(s) in conjunction with the travel arrangements for which I (We) are submitting this claim.

Please review the claim form to make sure all of the information provided is accurate and complete and that
all required documentation is included and sign below.

All statements contained in this form are true and complete to the best of my knowledge.

08 / ____
24 / ____
22 Susan Turkmen
Date Completed: ____ Your Name: ____________________________________________

Your Signature: _________________________________________

FR- 02-14

Trip Mate, Inc.*

PO BOX 527,
Nursen Turkmen
Hazelwood, MO 63042
310 DiamondBack Way
Algonquin IL, 60102 In CA & UT, dba Trip Mate Insurance Agency
844-777-6856 (Toll-Free) Fax: * E-mail: [email protected]
Page 3 of 5
 Claim ID: 7168503 Claim Type: TRC Plan Number: F560S

Important Notices (Please read and sign)

Fraud Warning: Any person who, with the intent to defraud or knowingly facilitates a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement, or conceals information for the purpose of misleading may be
guilty of insurance fraud and subject to criminal and/or civil penalties.

To determine eligibility for claim benefits, claim payment amounts, and identification and prevention of potential fraudulent activity,
the insurance company(ies) underwriting your policy, or its representatives, may disclose the claims information submitted to the
insurance company(ies), or its representatives, to any insurance support organization or fraud information clearinghouse utilized by
the insurance company(ies), or its representatives.

** ATTENTION: IF YOU ARE CLAIMING AIRLINE TICKETS, PLEASE COMPLETE THE BELOW. **

Your airline tickets may have value for up to one year from the original scheduled travel date. Please indicate below whether you
will be exchanging your ticket for another trip. Please note: Your signature on this agreement is not a guarantee of payment. All
final claim determinations are subject to eligibility and the terms of the policy.

___ I (We) will not be using our airline ticket(s). (Please include a copy of your electronic ticket confirmation(s) which includes your
ticket number(s).)

___ I (We) will be exchanging our airline ticket(s) for future travel. (Please submit documentation of the cost you incurred or will
incur to exchange your ticket(s).)

_X_ I (We) did not purchase airline ticket(s) in conjunction with the travel arrangements for which I (We) are submitting this claim.

Authorization For Release Of Information

In order to determine eligibility for claim benefits, claim payment amounts, and identification and prevention of potential fraudulent activity:
1. I authorize any physician; hospital or other medical or medically related facility or provider; insurance company; insurance
support organization, travel supplier or fraud information clearinghouse to release to: United States Fire Insurance Company, its
representatives or business associates assisting in the processing of the claim, any information regarding my medical history,
symptoms, treatment, examination results or diagnosis or such other information needed to determine claim benefits; and
2. I authorize United States Fire Insurance Company, its representatives or business associates assisting in the processing of my
claim, to disclose the claims information submitted to United States Fire Insurance Company, its representatives or business
associates assisting in the processing of my claim, to any insurance support organization or fraud information clearinghouse utilized
by United States Fire Insurance Company, or its representatives or business associates. A photocopy of this authorization shall be
considered as effective and valid as the original. This authorization shall be considered valid for a period not to exceed one year
from the date signed. I understand I have the right to receive a copy of this authorization and that I may revoke this authorization
at any time for information not then obtained upon my providing written notice of such revocation of the authorization to United
States Fire Insurance Company, its representatives or business associates assisting in the processing of my claim.

08 / ____
Date Completed: ____ 24 / ____
22 Patient's Name: ________________________________________
Nursen Y Turkmen
FIRST NAME MIDDLE INITIAL LAST NAME

Signature of Patient: ____________________________________

06 14
Patient's Date of Birth: ____ / ____ / ____
07

APS-ARI-USF-02-14

Trip Mate, Inc.*

Nursen Turkmen PO BOX 527,
Hazelwood, MO 63042
310 DiamondBack Way
Algonquin IL, 60102 In CA & UT, dba Trip Mate Insurance Agency
844-777-6856 (Toll-Free) Fax: * E-mail: [email protected]
Page 4 of 5
 Claim ID: 7168503 Claim Type: TRC Plan Number: F560S

ATTENDING PHYSICIAN’S STATEMENT

This form must be completed in full by the treating physician

Patient’s name ________________________________________________________ D.O.B. _____ / _____ / _____

Diagnosis _________________________________________________ ICD10 Code ________________________

Date of onset _____ / _____ / _____ Date first seen for this complaint _____ / _____ / _____

Has patient ever had treatment for same or similar condition? _____________ When? ______________________

Dates of hospitalization (if any) _____ / _____ / _____ through _____ / _____ / _____
_____ / _____ / _____ through _____ / _____ / _____
Surgical procedures (if any) and dates performed: _____________________________________________________
_____________________________________________________________________________________________
List other treatment/consultation and dates performed:_________________________________________________
_____________________________________________________________________________________________
Medications prescribed: _________________________________________________________________________
Name of referring physician: _______________________________________ When Referred? ________________
List other physicians treating patient for this condition.
Name ______________________________________________ When? __________________________
Name ______________________________________________ When? __________________________

If patient is the traveler, did this condition disable him/her from travel? Yes No

Inclusive dates of disability: From _____ / _____ / _____ through _____ / _____ / _____
If patient is a non-traveling family member, indicate dates the family member’s care and attendance was required:

From _____ / _____ / _____ through _____ / _____ / _____

Any false or misleading statement made in support of and resulting in a benefit payment shall be subject to legal action
for collection of damages against the person or persons making such false and/or misleading statements.

Date completed _____ / _____ / _____ Physician’s signature __________________________________

Physician name__________________________________ Physician telephone ( _____ ) ___________________

Physician address _______________________________ Physician facsimile ( _____ ) ___________________

______________________________________________ Tax identification # ____________________________

APS-ARI-USF- 02-14

Return This Form To:

Trip Mate, Inc.*
PO BOX 527,
Nursen Turkmen
Hazelwood, MO 63042
310 DiamondBack Way
Algonquin IL, 60102 In CA & UT, dba Trip Mate Insurance Agency
844-777-6856 (Toll-Free) Fax: * E-mail: [email protected]
Page 5 of 5