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• Request a Claim Form

  
  

  Please fill out this short form to enable us to get your claim process started and to send you the correct claim form(s).

  Important note: If you've already contacted us to start your claim, please be patient. There is no need to submit again.

  • Policy Number
    
  • Did you book your trip online? *

    Yes No
  • Name of website *
  • Name of travel provider *

    Your travel provider is the one with whom you booked your travel: online travel agency, cruise line, tour operator, etc.

  • Is this a trip cancellation ? *
    Yes No
  • 
    Step 1: Notify Priceline that you are unable to travel
    
    Step 2: View reasons for which you may be eligible to receive reimbursement
    
  • 1. Your, an immediate family member's, traveling companion's, or business partner's sickness, injury or death; or
    2. You, an immediate family member traveling with you, or traveling companion:
    1. being directly involved in a documented traffic accident while en route to departure;
    2. being hijacked, quarantined, required to serve on a jury, or required by a court order to appear as a witness in a legal action, provided you, an immediate family member traveling with you or a traveling companion is not: 1) a party to the legal action, or 2) appearing as a law enforcement officer;
    3. having your home made uninhabitable by fire, flood, volcano, earthquake, hurricane or other natural disaster;
    4. a terrorist act which occurs in your departure city or in a city which is a scheduled destination for your covered trip provided: the terrorist act occurs within 30 days of the scheduled travel date for your covered trip;
    5. your involuntary termination of employment or layoff which occurs after your effective date of coverage and was not under your control. You must have been continuously employed with the same employer for 3 years prior to the termination or layoff. This provision is not applicable to temporary employment, independent contractors or self-employed persons;
    6. your host at destination is hospitalized or dies (applicable only to flight cancellation);
    7. a natural disaster occurs, which causes a complete cessation of travel services at point of departure and/or destination;
    8. terrorism occurs in a country included on your travel itinerary which leads the U.S. government to issue a travel warning against travel within a country included on your travel itinerary for a period that would include your scheduled covered trip; or
    9. your, a traveling immediate family member's or traveling companion's approved, written military leave is involuntarily revoked as a result of being temporarily or permanently reassigned, being called into active military reserve or an extension of deployment beyond a defined tour of duty within 30 days of departure. All leave must be approved prior to the Policy effective date.
    View Exclusions
    
    Exclusions

    1. mental, nervous, or psychological disorders, except if hospitalized;
    2. being under the influence of drugs or intoxicants, unless prescribed by a Physician;
    3. normal pregnancy, except if hospitalized; or elective abortion;
    4. riding or driving in any motor competition;
    5. declared or undeclared war, or any act of war;
    6. service in the armed forces of any country;
    7. operating or learning to operate any aircraft, as pilot or crew;
    8. any unlawful acts, committed by you or a Traveling Companion (whether insured or not);
    9. any amount paid or payable under any Worker's Compensation, Disability Benefit or similar law;
    10. elective Treatment and Procedures;
    11. medical treatment during or arising from a Covered Trip undertaken for the purpose or intent of securing medical treatment;
    12. business, contractual or educational obligations of you, an Immediate Family Member or Traveling Companion;
    13. failure of any tour operator, Common Carrier, or other travel supplier, person or agency to provide the bargained-for travel arrangements;
    14. a loss that results from an illness, disease, or other condition, event or circumstance which occurs at a time when the plan is not in effect for you.

    This is not a complete description of coverage. View your specific plan terms, conditions, and exclusions for more details or call us at 877-892-7951.
  • Travel Dates:
    Departure * Return
  • Booking number

  • Claimant 1 (Claim Contact)

    You can add other claimants by clicking the Add Claimant button.
  • Title *
    --- Select --- Mr. Miss Mrs. Ms. Dr.
  • Name *
    First Last
  • Country *
    USAAfghanistanAlbaniaAlgeriaAndorraAngolaAntiguaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelgiumBelizeBeninBhutanBoliviaBosnia & HerzegovinaBotswanaBrazilBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaChadChileChinaColombiaComorosCongoCosta RicaCroatiaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGrenadaGuamGuatemalaGuineaGuinea BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKoreaKosovoKuwaitKyrgyzstanLao RepublicLatviaLebanonLesothoLiberiaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMilitary APOMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts & NevisSaint LuciaSamoaSan MarinoSao Tome & PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSouth AfricaSpainSri LankaSt Vincent & GrenadiSudanSurinameSwazilandSwedenSwitzerlandTaiwanTajikistanTanzaniaThailandTimorTogoTongaTrinidadTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietNamZambiaZimbabwe
  • Address line 1 *
  • Address line 2
  • City *
  • State *
    --- Select --- AlabamaAlaskaAmerican EmbassyArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMilitary APMilitary AAMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming
  • Province *
    --- Select --- AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundlandNorthwest TerritoryNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon
  • Zip Code *
  • State or Province of residence *
    Select State Outside USA and Canada AlabamaAlaskaAmerican EmbassyArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMilitary APMilitary AAMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundlandNorthwest TerritoryNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon
  • Phone Number *
  • Email *
  • Confirm Email *
  • How would you like to receive your claim form(s)? *
    EMAIL MAIL
  • Available claim types *

    Trip CancellationMedical ExpensesTrip InterruptionRental Car DamageTrip DelaySecurity DepositBag DelayLost/Damaged Baggage

    Hover on the claimtype to see its description here.

  • Please tell us the reason for your claim *

If cancelling a trip, please remember to notify your travel provider of the cancellation.
If your plan includes "Trip Cancellation" protection you may be entitled to reimbursement (up to the dollar limit specified in your plan) if you are prevented from taking your trip due to a covered reason. Please refer to your plan description for further explanation.

If your plan includes "Trip Interruption" protection you may be entitled to reimbursement (up to the dollar limit specified in your plan) if you are prevented from completing your trip due to a covered reason. Please refer to your plan description for further explanation.

If your plan includes "Trip Delay" or "Travel Delay" protection and the flights departing to, or returning from, your travel arrangements (tour, cruise or other) are substantially delayed, you may be entitled to reimbursement of the cost of catching up with your trip, or for the expenses resulting from delays returning home - up to the dollar limit specified in your plan.

Reimbursable expenses may include additional airfare, meal and lodging expenses (if not provided by your airline). The coverage may also include reimbursement for the days of your trip that are missed, again, up to the trip delay coverage limit indicated in your plan description brochure. Per day limits may also apply. The trip delay coverage usually "kicks in" after delays of a specified number of hours, also indicated in your plan description.

If your plan includes "Baggage Protection" you may be entitled to reimbursement for loss, theft or damage to baggage and personal effects. Additionally, you may be entitled for reimbursement for expenses of necessary personal effects purchased while at a destination other than your place of residence if your bag was delayed or misdirected by a Common Carrier for more than 24 hours from the time you arrived at the destination stated on your ticket. You must be a ticketed passenger on a Common Carrier. The amount of the reimbursement is not to exceed the dollar limit specified in your plan.

If your plan includes "Baggage Protection" you may be entitled to reimbursement for loss, theft or damage to baggage and personal effects. Additionally, you may be entitled for reimbursement for expenses of necessary personal effects purchased while at a destination other than your place of residence if your bag was delayed or misdirected by a Common Carrier for more than 24 hours from the time you arrived at the destination stated on your ticket. You must be a ticketed passenger on a Common Carrier. The amount of the reimbursement is not to exceed the dollar limit specified in your plan.

If your plan includes "Rental Car Damage" protection and if while on a covered trip your rental car is damaged due to a covered reason, you may be entitled to reimbursement (up to the dollar limit specified in your plan). Please refer to your plan description for further explanation.

Provides reimbursement (up to the dollar limit specified in the plan description) to a property owner for covered damages that occur to their property as a result of a renter. Please refer to your plan description for further explanation.

If your plan includes "Medical Protection" you may be entitled to reimbursement for Emergency Evacuation, Repatriation of Remains and Accident and Sickness Medical Expense. Please refer to your Description of Coverage for more details and plan dollar limits.

Hover on the claimtype to see its description here.