Trip Cancellation Claim

Guidelines
All fields with an asterisk are required. In the final step, you will be asked to attach documentation relevant to your claim. Acceptable forms of proof of payment include:
  • A credit card statement and/or a copy of the front and back of the negotiated check
  • Copies of the invoice/reservation for hotel, cruise, and tour bookings
  • Airline ticket, e-ticket
  • Travel supplier cancellation notice
  • If cancellation was the result of an illness/injury, please have the patient’s physician complete the “Physician’s Statement” found here. The completed form can be emailed to claims@sevencorners.com and the claim number should be referenced in the subject line.
  • File types allowed: pdf, doc, txt, jpeg, tif, bmp, gif, png. You can take a photo of your documents and upload the photo files.

If you need help finding your certificate number or other information, give us a call 800-690-6295 (toll free) or 317-818-2808 (collect).

Primary Insured (Information must match exactly what is on your ID card.)
Who cancelled their trip?
Travel Details
Are You Claiming Airline Tickets? Your airline tickets may have value up to one year from the original scheduled departure date.
Please indicate below whether you will be exchanging your tickets for another trip. Upload a copy of all electronic
ticket confirmations and costs incurred at the end of this form.
Do you have any other insurance?
Was the cancellation due to medical reasons?
Medical Claim Information
Was the person hospitalized for the mentioned symptoms or illness?
Has the person received medical attention for the mentioned symptoms or illness?
Payment Information
Method of Payment*
ACH/EFT: US $ Canada(CAD) $
Country
International/non-U.S. Account Information

Complete for payment through bank transfer outside the U.S.

Account type
Signature
Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. In submitting this claim to Seven Corners, Inc., I declare that I have read & understood my policy’s terms and conditions and agree to the privacy policy and to the Fraud Notices.

I hereby authorize Seven Corners, Inc. (hereinafter COMPANY) to mail any payments to the above listed address and to deposit any amounts owed me for reimbursement of medical expenses or services rendered by initiating credit entries to my account at the financial institution (hereby BANK) indicated above. Further, I authorize BANK to accept and to credit any credit entries indicated by COMPANY to my account. In the event that COMPANY erroneously deposits funds in my account (by way of example, I am not entitled to the funds or the amount of deposit Is incorrect or such funds are deposited in the wrong account), I authorize COMPANY to debit or credit my account in the amount necessary to correct the initial deposit, but in no case shall any debit exceed the amount of the initial deposit. I further agree COMPANY is not responsible for any transaction fees charged and will release Seven Corners of any liability in the event of lost or stolen payments.

Document Upload
Please submit proof of payment for claimed expenses. You can take a photo of your documents and upload the photo files. Acceptable forms of proof of payment include:
  • A credit card statement and/or a copy of the front and back of the negotiated check
  • Copies of the invoice/reservation for hotel, cruise, and tour bookings
  • Airline ticket, e-ticket
  • Travel supplier cancellation notice
  • If cancellation was the result of an illness/injury, please have the patient’s physician complete the “Physician’s Statement” found here. The completed form can be emailed to claims@sevencorners.com and the claim number should be referenced in the subject line.
  • File types allowed: pdf, doc, txt, jpeg, tif, bmp, gif, png. You can take a photo of your documents and upload the photo files.

Documents

Privacy Information
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Security Statement

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