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Holiday sickness
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Holiday sickness
1
Your details
2
Criteria
3
Circumstances
4
Reporting
5
Additional claimants
Client Details
Name
*
First
Last
Address
*
Street Address
Address Line 2
State / Province / Region
ZIP / Postal Code
Landline No
*
Mobile No
*
Email
*
Date of Birth
*
National Insurance No
*
Employer Status
*
Employed
Self Employed
Retired
Job Title
*
Section 1 - The Criteria
All-Inclusive/Half/Full Board (2.5 Years)
*
Yes
No
At hotel/resort 72 hours before illness
*
Yes
No
Accepted any discount from Tour Operator?
*
Yes
No
Reported to Holiday Rep
*
Yes
No
7 Days Minimum Symptoms?
*
Yes
No
Booking Info/ATOL Certificate?
*
Yes
No
Section 2 - The Booking Operator and Hotel/Resort
Tour Operator
*
Address
*
Street Address
City
ZIP / Postal Code
Resort
Resort Name
*
Resort Address
*
Street Address
City
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
Hotel
Hotel Name
Hotel Address
*
Street Address
City
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
Departure Date:
*
Return Date:
*
Booked online
*
Yes
No
Operator/Booking Ref:
*
Special Occasion?
*
Honeymoon
Anniversary
Birthday
Annual Holiday
Section 3 – The Circumstances and Illness
Symptoms:
*
Stomach Cramps
Nose bleeds
Constipation
Rash/Skin Problems
Diarrhoea
Blurred Vision
Bed-Bound
Sleep Disturbance
Nausea
Temperature
Injections
Sore Throat
Vomiting
Feeling Fatigued
Intravenous Drip
Other
Other:
Start of Illness:
OR Number of Days after start of holiday:
Is your illness ongoing?
*
Yes
No
Duration of illness
*
Eat or Drink at the Hotel/Resort?
*
Yes
No
What caused the Illness?
*
Did you eat outside the hotel/premises before you got ill or on an excursion?
*
Yes
No
Did you notice the smell of food that had “gone off”?
*
Yes
No
Did you notice any other smells at the hotel/premises?
*
Yes
No
Was the food in the hotel/premises left uncovered i.e. in a buffet?
*
Yes
No
Did any animals have access to this food e.g. insects, birds or other animals?
*
Yes
No
Did staff handle food without gloves?
*
Yes
No
Were there any other guests who were sick?
*
Yes
No
Were drinks served with ice/local water from non-bottled sources?
*
Yes
No
Section 4 – Reporting the illness/infection
Did you report the illness/infection to the hotel/premises representative? If so on what date and to who? Do you have a copy of the report?
*
Do you have photographs of the hotel/premises?
*
Yes
No
Please provide photos
*
Drop files here or
Has there been any official investigation?
*
Yes
No
Has there been any admission of liability (blame) by the hotel/premises?
*
Yes
No
Were you advised at the hotel/premises as to what infection/illness you suffered? If so by whom?
*
Were you treated by an on-site medical doctor?
*
Yes
No
Did you visit your own GP upon your return to the UK?
*
Yes
No
Do you have any documentary evidence?
*
Yes
No
Was a stool sample taken for analysis by an on-site doctor or by your GP?
*
Yes
No
Did you self-medicate at the resort or back in the UK?
*
Yes
No
Did you self-medicate at the resort or back in the UK?
*
Yes
No
If so, please provide pay slips (or accounts if self-employed) for 13 weeks prior to the illness and confirm between what dates you were absent
Section 5 – Additional Claimants
How many additional claimants are there?
*
No additional claimants
One additional claimant
Two additional claimants
Three additional claimants
Four additional claimants
Five additional claimants
Six additional claimants
2nd Claimant
Name
*
First
Last
Address
*
Street Address
City
ZIP / Postal Code
National Insurance No:
*
Employment Status
*
Employed
Self-employed
Retired
Job Title:
*
Injuries and duration of suffering (if same, please write same)
*
3rd Claimant
Name
*
First
Last
Address
*
Street Address
City
ZIP / Postal Code
National Insurance No:
*
Employment Status
*
Employed
Self-employed
Retired
Employment Status
*
Employed
Self-employed
Retired
Job Title:
*
Injuries and duration of suffering (if same, please write same)
*
4th Claimant
Name
*
First
Last
Address
*
Street Address
City
ZIP / Postal Code
National Insurance No:
*
Employment Status
*
Employed
Self-employed
Retired
Job Title:
*
Injuries and duration of suffering (if same, please write same)
*
5th Claimant
Name
*
First
Last
Address
*
Street Address
City
ZIP / Postal Code
National Insurance No:
*
Employment Status
*
Employed
Self-employed
Retired
Job Title:
*
Injuries and duration of suffering (if same, please write same)
*
6th Claimant
Name
*
First
Last
Address
*
Street Address
City
ZIP / Postal Code
National Insurance No:
*
Employment Status
*
Employed
Self-employed
Retired
Job Title:
*
Injuries and duration of suffering (if same, please write same)
*
6th Claimant
Name
*
First
Last
Address
*
Street Address
City
ZIP / Postal Code
National Insurance No:
*
Employment Status
*
Employed
Self-employed
Retired
Job Title:
*
Injuries and duration of suffering (if same, please write same)
*
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