www.worldtrips.com
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2606:4700::6812:1b14
Public Scan
Submitted URL: https://service.worldtrips.com/
Effective URL: https://www.worldtrips.com/customer-service
Submission: On February 19 via automatic, source certstream-suspicious — Scanned from DE
Effective URL: https://www.worldtrips.com/customer-service
Submission: On February 19 via automatic, source certstream-suspicious — Scanned from DE
Form analysis 3 forms found in the DOM
Name: frmClaimRequest —
<form name="frmClaimRequest" ng-submit="submitClaimForm()" class="ng-pristine ng-invalid ng-invalid-required ng-valid-maxlength ng-valid-email">
<div class="modal-header modal-header-center">
<button aria-label="Close" class="close" data-dismiss="modal" type="button"> <span aria-hidden="true">×</span> </button>
<h4 class="modal-title">Submit Claim Request</h4>
<p>Have a question about a claim? Visit our
<a rel="noopener noreferrer" href="https://www.worldtrips.com/claims-resource-center/?__hstc=95757827.93e79874ee2e215c025ae6ff5c96bcb1.1618853283280.1631296919301.1631538429390.176&__hssc=95757827.1.1631538429390&__hsfp=3770066040" target="_blank">Claims Center</a>!
</p>
</div>
<div class="modal-body row">
<div class="col-xs-12 form-group">
<br>
<label for="claim.ForeignCurrency" name="radioOpt">Does this claim include foreign currency? (i.e. currency other than USD)</label><select class="form-control ng-pristine ng-untouched ng-empty ng-invalid ng-invalid-required"
id="claim.ForeignCurrency" ng-model="claim.ForeignCurrency" required="required">
<option value="? undefined:undefined ?" selected="selected"></option>
<option value="
">
</option>
<option value="no">No </option>
<option value="yes">Yes </option>
</select>
</div>
<div class="col-xs-12 form-group">
<label>Select Submission Type</label>
<div><label class="radio-inline"> <input id="newClaim" ng-model="claim.RequestType" ng-value="'new'" type="radio" class="ng-pristine ng-untouched ng-valid ng-empty" name="3" value="new">New Claim </label> <label class="radio-inline"> <input
id="existingClaim" ng-model="claim.RequestType" ng-value="'existing'" type="radio" class="ng-pristine ng-untouched ng-valid ng-empty" name="4" value="existing">Existing Claim </label></div>
<div class="notice" style="display: none;">
<p>If you have not yet completed a Claimant's Statement for the condition related to this claim, please log in to the
<a rel="noopener noreferrer" href="https://zone.worldtrips.com/clientzone/?__hstc=95757827.93e79874ee2e215c025ae6ff5c96bcb1.1618853283280.1631296919301.1631538429390.176&__hssc=95757827.1.1631538429390&__hsfp=3770066040" target="_blank">Client Zone</a>
to complete the Claimant's Statement electronically, or you may download it
<a rel="noopener noreferrer" href="https://www.worldtrips.com/downloads/hccmis_claimants_statement.pdf?__hstc=95757827.93e79874ee2e215c025ae6ff5c96bcb1.1618853283280.1631296919301.1631538429390.176&__hssc=95757827.1.1631538429390&__hsfp=3770066040" target="_blank">here</a>.
</p>
</div>
</div>
<div class="col-xs-12 form-group"><label for="claim.CertNumber"> Certificate Number
<a class="my-tool-tip" data-placement="right" data-toggle="tooltip" title="" data-original-title="Please refer to the Certificate # located on your ID Card or fulfillment document."> <span class="fas fa-info-circle"></span> </a> <span
class="asterisk">*</span> </label> <input class="form-control ng-pristine ng-untouched ng-empty ng-invalid ng-invalid-required ng-valid-maxlength" id="claim.CertNumber" maxlength="50" ng-model="claim.CertNumber"
placeholder="Enter Certificate # (i.e. AK1234567890)" required="required" type="text"></div>
<div class="col-xs-12 form-group">
<label for="claim.dobM"> Date of Birth <span class="asterisk">*</span> </label>
<div class="form-inline">
<div class="form-group">
<select class="form-control dobControl ng-pristine ng-untouched ng-empty ng-invalid ng-invalid-required" id="claim.dobM" ng-model="claim.dobM" required="required">
<option value="? undefined:undefined ?" selected="selected"></option>
<option value="
">
</option>
<option value="1">Jan </option>
<option value="2">Feb </option>
<option value="3">Mar </option>
<option value="4">Apr </option>
<option value="5">May </option>
<option value="6">Jun </option>
<option value="7">Jul </option>
<option value="8">Aug </option>
<option value="9">Sep </option>
<option value="10">Oct </option>
<option value="11">Nov </option>
<option value="12">Dec </option>
</select><select class="form-control dobControl ng-pristine ng-untouched ng-empty ng-invalid ng-invalid-required" id="claim.dobD" ng-model="claim.dobD" required="required">
<option value="? undefined:undefined ?" selected="selected"></option>
<option value="
">
</option>
<option value="1">1 </option>
<option value="2">2 </option>
<option value="3">3 </option>
<option value="4">4 </option>
<option value="5">5 </option>
<option value="6">6 </option>
<option value="7">7 </option>
<option value="8">8 </option>
<option value="9">9 </option>
<option value="10">10 </option>
<option value="11">11 </option>
<option value="12">12 </option>
<option value="13">13 </option>
<option value="14">14 </option>
<option value="15">15 </option>
<option value="16">16 </option>
<option value="17">17 </option>
<option value="18">18 </option>
<option value="19">19 </option>
<option value="20">20 </option>
<option value="21">21 </option>
<option value="22">22 </option>
<option value="23">23 </option>
<option value="24">24 </option>
<option value="25">25 </option>
<option value="26">26 </option>
<option value="27">27 </option>
<option value="28">28 </option>
<option value="29">29 </option>
<option value="30">30 </option>
<option value="31">31 </option>
</select><select class="form-control dobControl doby ng-pristine ng-untouched ng-empty ng-invalid ng-invalid-required" id="claim.dobY" ng-model="claim.dobY" required="required">
<!-- ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="" class="ng-binding ng-scope" selected="selected">
</option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2022" class="ng-binding ng-scope">2022 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2021" class="ng-binding ng-scope">2021 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2020" class="ng-binding ng-scope">2020 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2019" class="ng-binding ng-scope">2019 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2018" class="ng-binding ng-scope">2018 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2017" class="ng-binding ng-scope">2017 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2016" class="ng-binding ng-scope">2016 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2015" class="ng-binding ng-scope">2015 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2014" class="ng-binding ng-scope">2014 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2013" class="ng-binding ng-scope">2013 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2012" class="ng-binding ng-scope">2012 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2011" class="ng-binding ng-scope">2011 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2010" class="ng-binding ng-scope">2010 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2009" class="ng-binding ng-scope">2009 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2008" class="ng-binding ng-scope">2008 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2007" class="ng-binding ng-scope">2007 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2006" class="ng-binding ng-scope">2006 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2005" class="ng-binding ng-scope">2005 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2004" class="ng-binding ng-scope">2004 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2003" class="ng-binding ng-scope">2003 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2002" class="ng-binding ng-scope">2002 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2001" class="ng-binding ng-scope">2001 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2000" class="ng-binding ng-scope">2000 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1999" class="ng-binding ng-scope">1999 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1998" class="ng-binding ng-scope">1998 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1997" class="ng-binding ng-scope">1997 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1996" class="ng-binding ng-scope">1996 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1995" class="ng-binding ng-scope">1995 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1994" class="ng-binding ng-scope">1994 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1993" class="ng-binding ng-scope">1993 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1992" class="ng-binding ng-scope">1992 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1991" class="ng-binding ng-scope">1991 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1990" class="ng-binding ng-scope">1990 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1989" class="ng-binding ng-scope">1989 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1988" class="ng-binding ng-scope">1988 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1987" class="ng-binding ng-scope">1987 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1986" class="ng-binding ng-scope">1986 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1985" class="ng-binding ng-scope">1985 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1984" class="ng-binding ng-scope">1984 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1983" class="ng-binding ng-scope">1983 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1982" class="ng-binding ng-scope">1982 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1981" class="ng-binding ng-scope">1981 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1980" class="ng-binding ng-scope">1980 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1979" class="ng-binding ng-scope">1979 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1978" class="ng-binding ng-scope">1978 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1977" class="ng-binding ng-scope">1977 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1976" class="ng-binding ng-scope">1976 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1975" class="ng-binding ng-scope">1975 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1974" class="ng-binding ng-scope">1974 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1973" class="ng-binding ng-scope">1973 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1972" class="ng-binding ng-scope">1972 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1971" class="ng-binding ng-scope">1971 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1970" class="ng-binding ng-scope">1970 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1969" class="ng-binding ng-scope">1969 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1968" class="ng-binding ng-scope">1968 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1967" class="ng-binding ng-scope">1967 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1966" class="ng-binding ng-scope">1966 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1965" class="ng-binding ng-scope">1965 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1964" class="ng-binding ng-scope">1964 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1963" class="ng-binding ng-scope">1963 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1962" class="ng-binding ng-scope">1962 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1961" class="ng-binding ng-scope">1961 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1960" class="ng-binding ng-scope">1960 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1959" class="ng-binding ng-scope">1959 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1958" class="ng-binding ng-scope">1958 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1957" class="ng-binding ng-scope">1957 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1956" class="ng-binding ng-scope">1956 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1955" class="ng-binding ng-scope">1955 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1954" class="ng-binding ng-scope">1954 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1953" class="ng-binding ng-scope">1953 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1952" class="ng-binding ng-scope">1952 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1951" class="ng-binding ng-scope">1951 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1950" class="ng-binding ng-scope">1950 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1949" class="ng-binding ng-scope">1949 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1948" class="ng-binding ng-scope">1948 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1947" class="ng-binding ng-scope">1947 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1946" class="ng-binding ng-scope">1946 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1945" class="ng-binding ng-scope">1945 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1944" class="ng-binding ng-scope">1944 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1943" class="ng-binding ng-scope">1943 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1942" class="ng-binding ng-scope">1942 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1941" class="ng-binding ng-scope">1941 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1940" class="ng-binding ng-scope">1940 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1939" class="ng-binding ng-scope">1939 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1938" class="ng-binding ng-scope">1938 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1937" class="ng-binding ng-scope">1937 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1936" class="ng-binding ng-scope">1936 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1935" class="ng-binding ng-scope">1935 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1934" class="ng-binding ng-scope">1934 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1933" class="ng-binding ng-scope">1933 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1932" class="ng-binding ng-scope">1932 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1931" class="ng-binding ng-scope">1931 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1930" class="ng-binding ng-scope">1930 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1929" class="ng-binding ng-scope">1929 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1928" class="ng-binding ng-scope">1928 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1927" class="ng-binding ng-scope">1927 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1926" class="ng-binding ng-scope">1926 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1925" class="ng-binding ng-scope">1925 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1924" class="ng-binding ng-scope">1924 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1923" class="ng-binding ng-scope">1923 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1922" class="ng-binding ng-scope">1922 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1921" class="ng-binding ng-scope">1921 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1920" class="ng-binding ng-scope">1920 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1919" class="ng-binding ng-scope">1919 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1918" class="ng-binding ng-scope">1918 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1917" class="ng-binding ng-scope">1917 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1916" class="ng-binding ng-scope">1916 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1915" class="ng-binding ng-scope">1915 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1914" class="ng-binding ng-scope">1914 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1913" class="ng-binding ng-scope">1913 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1912" class="ng-binding ng-scope">1912 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1911" class="ng-binding ng-scope">1911 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1910" class="ng-binding ng-scope">1910 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1909" class="ng-binding ng-scope">1909 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1908" class="ng-binding ng-scope">1908 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1907" class="ng-binding ng-scope">1907 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1906" class="ng-binding ng-scope">1906 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1905" class="ng-binding ng-scope">1905 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1904" class="ng-binding ng-scope">1904 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1903" class="ng-binding ng-scope">1903 </option><!-- end ngRepeat: item in dobyears -->
</select>
</div>
</div>
</div>
<div class="col-xs-12 form-group"><label for="claim.EmailAddress"> Email Address <span class="asterisk">*</span> </label> <input
class="form-control ng-pristine ng-untouched ng-empty ng-valid-email ng-invalid ng-invalid-required ng-valid-maxlength" id="claim.EmailAddress" maxlength="100" ng-model="claim.EmailAddress" placeholder="Enter your email address"
required="required" type="email"></div>
<div class="col-xs-12 form-group"><label for="claim.ClaimNumber"> Claim Number </label> <input class="form-control ng-pristine ng-untouched ng-valid ng-empty ng-valid-maxlength" id="claim.ClaimNumber" maxlength="50" ng-model="claim.ClaimNumber"
placeholder="Enter your claim number (i.e. 214-1234567890-00)" type="text"></div>
<div class="col-xs-12" id="claimsUploads">
<label for="uploadFileLabel">Upload Files</label> <br>
<em style="font-size: 1rem;"> Note: If you are filing this claim on behalf of another person, you MUST include the
<a rel="noopener noreferrer" href="https://www.worldtrips.com/downloads/intl_auth_for_release_of_phi.pdf?__hstc=95757827.93e79874ee2e215c025ae6ff5c96bcb1.1618853283280.1631296919301.1631538429390.176&__hssc=95757827.1.1631538429390&__hsfp=3770066040" target="_blank">Authorization Form</a>
signed by the policyholder in order to speak with us about the claim. Without this signed form, it is a violation of HIPAA for us to talk with you regarding another person's insurance claim. </em> <br>
<br>
<div class="form-group">
<input class="file" file-model="claim.File1" id="claim.File1" multiple="multiple" type="file" style="display: none;">
<div class="input-group col-xs-12"><input class="form-control input-sm fileinput" disabled="disabled" id="claim.File1Disp" placeholder="Choose file (.pdf, .png, .jpg, .jpeg, .gif, .docx only)" type="text"> <span class="input-group-btn">
<button class="btn btn-default input-sm browse" type="button">Upload</button> <button class="btn btn-default input-sm lower" ng-click="clearInputFile('claim.File1')" type="button">Remove</button> </span></div>
</div>
<div class="form-group">
<input class="file" file-model="claim.File2" id="claim.File2" multiple="multiple" type="file" style="display: none;">
<div class="input-group col-xs-12"><input class="form-control input-sm fileinput" disabled="disabled" id="claim.File2Disp" placeholder="Choose file (.pdf, .png, .jpg, .jpeg, .gif, .docx only)" type="text"> <span class="input-group-btn">
<button class="btn btn-default input-sm browse" type="button">Upload</button> <button class="btn btn-default input-sm lower" ng-click="clearInputFile('claim.File2')" type="button">Remove</button> </span></div>
</div>
<div class="form-group">
<input class="file" file-model="claim.File3" id="claim.File3" multiple="multiple" type="file" style="display: none;">
<div class="input-group col-xs-12"><input class="form-control input-sm fileinput" disabled="disabled" id="claim.File3Disp" placeholder="Choose file (.pdf, .png, .jpg, .jpeg, .gif, .docx only)" type="text"> <span class="input-group-btn">
<button class="btn btn-default input-sm browse" type="button">Upload</button> <button class="btn btn-default input-sm lower" ng-click="clearInputFile('claim.File3')" type="button">Remove</button> </span></div>
</div>
<div class="form-group">
<input class="file" file-model="claim.File4" id="claim.File4" multiple="multiple" type="file" style="display: none;">
<div class="input-group col-xs-12"><input class="form-control input-sm fileinput" disabled="disabled" id="claim.File4Disp" placeholder="Choose file (.pdf, .png, .jpg, .jpeg, .gif, .docx only)" type="text"> <span class="input-group-btn">
<button class="btn btn-default input-sm browse" type="button">Upload</button> <button class="btn btn-default input-sm lower" ng-click="clearInputFile('claim.File4')" type="button">Remove</button> </span></div>
</div>
<div class="form-group">
<input class="file" file-model="claim.File5" id="claim.File5" multiple="multiple" type="file" style="display: none;">
<div class="input-group col-xs-12"><input class="form-control input-sm fileinput" disabled="disabled" id="claim.File5Disp" placeholder="Choose file (.pdf, .png, .jpg, .jpeg, .gif, .docx only)" type="text"> <span class="input-group-btn">
<button class="btn btn-default input-sm browse" type="button">Upload</button> <button class="btn btn-default input-sm lower" ng-click="clearInputFile('claim.File5')" type="button">Remove</button> </span></div>
</div>
</div>
</div>
<div class="modal-footer">
<div class="pull-left"><span class="asterisk">*</span> <em>Indicates required field</em></div>
<button class="btn btn-primary" type="submit">Submit</button>
</div>
</form>Name: frmAppeal —
<form name="frmAppeal" ng-submit="submitAppealForm()" class="ng-pristine ng-invalid ng-invalid-required ng-valid-maxlength ng-valid-email">
<div class="modal-header modal-header-center">
<button aria-label="Close" class="close" data-dismiss="modal" type="button"> <span aria-hidden="true">×</span> </button>
<h4 class="modal-title">Claimant Appeal Request Form</h4>
<h5>Don't have an Appeals form? Click
<a rel="noopener noreferrer" href="https://www.worldtrips.com/downloads/claimant_appeal_request_form.pdf?__hstc=95757827.93e79874ee2e215c025ae6ff5c96bcb1.1618853283280.1631296919301.1631538429390.176&__hssc=95757827.1.1631538429390&__hsfp=3770066040" target="_blank">here</a>
to download or complete the form below. <br>
<br>
<em> You may use this form to appeal a coverage decision or you can request an appeal by following the appeal procedure outlined in your certificate of coverage. </em>
</h5>
</div>
<div class="modal-body">
<label for="policyNumber"> Insured Name <span class="asterisk">*</span> </label> <input class="form-control ng-pristine ng-untouched ng-empty ng-invalid ng-invalid-required ng-valid-maxlength" maxlength="100" ng-model="appeal.InsuredName"
placeholder="Enter insured's name" required="required" type="text"> <label for="mailingAddress"> Mailing Address <span class="asterisk">*</span> </label> <textarea
class="form-control form-inline ng-pristine ng-untouched ng-empty ng-invalid ng-invalid-required ng-valid-maxlength" maxlength="500" ng-model="appeal.MailingAddress" placeholder="Include Street Address, City, State, Country, and Postal Code"
required="required"></textarea> <label for="patientName"> Claimant (Patient) Name <span class="asterisk">*</span> </label> <input class="form-control ng-pristine ng-untouched ng-empty ng-invalid ng-invalid-required ng-valid-maxlength"
maxlength="100" ng-model="appeal.ClaimantName" placeholder="Enter the patient's name" required="required" type="text"> <label for="certNumber"> Certificate #
<a class="my-tool-tip" data-placement="right" data-toggle="tooltip" title="" data-original-title="Please refer to the Certificate # on your ID Card or fulfillment document."> <span class="fas fa-info-circle"></span> </a> <span
class="asterisk">*</span> </label> <input class="form-control ng-pristine ng-untouched ng-empty ng-invalid ng-invalid-required ng-valid-maxlength" maxlength="50" ng-model="appeal.CertNumber"
placeholder="Enter Certificate # (i.e. AK1234567890)" required="required" type="text">
<div>
<label for="dateOfBirth"> Date of Birth <span class="asterisk">*</span> </label>
<div class="form-inline">
<div class="form-group">
<select class="form-control dobControl ng-pristine ng-untouched ng-empty ng-invalid ng-invalid-required" ng-model="appeal.dobM" required="required">
<option value="? undefined:undefined ?" selected="selected"></option>
<option value="
">
</option>
<option value="1">Jan </option>
<option value="2">Feb </option>
<option value="3">Mar </option>
<option value="4">Apr </option>
<option value="5">May </option>
<option value="6">Jun </option>
<option value="7">Jul </option>
<option value="8">Aug </option>
<option value="9">Sep </option>
<option value="10">Oct </option>
<option value="11">Nov </option>
<option value="12">Dec </option>
</select><select class="form-control dobControl ng-pristine ng-untouched ng-empty ng-invalid ng-invalid-required" ng-model="appeal.dobD" required="required">
<option value="? undefined:undefined ?" selected="selected"></option>
<option value="
">
</option>
<option value="1">1 </option>
<option value="2">2 </option>
<option value="3">3 </option>
<option value="4">4 </option>
<option value="5">5 </option>
<option value="6">6 </option>
<option value="7">7 </option>
<option value="8">8 </option>
<option value="9">9 </option>
<option value="10">10 </option>
<option value="11">11 </option>
<option value="12">12 </option>
<option value="13">13 </option>
<option value="14">14 </option>
<option value="15">15 </option>
<option value="16">16 </option>
<option value="17">17 </option>
<option value="18">18 </option>
<option value="19">19 </option>
<option value="20">20 </option>
<option value="21">21 </option>
<option value="22">22 </option>
<option value="23">23 </option>
<option value="24">24 </option>
<option value="25">25 </option>
<option value="26">26 </option>
<option value="27">27 </option>
<option value="28">28 </option>
<option value="29">29 </option>
<option value="30">30 </option>
<option value="31">31 </option>
</select><select class="form-control dobControl doby ng-pristine ng-untouched ng-empty ng-invalid ng-invalid-required" ng-model="appeal.dobY" required="required">
<!-- ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="" class="ng-binding ng-scope" selected="selected">
</option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2022" class="ng-binding ng-scope">2022 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2021" class="ng-binding ng-scope">2021 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2020" class="ng-binding ng-scope">2020 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2019" class="ng-binding ng-scope">2019 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2018" class="ng-binding ng-scope">2018 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2017" class="ng-binding ng-scope">2017 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2016" class="ng-binding ng-scope">2016 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2015" class="ng-binding ng-scope">2015 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2014" class="ng-binding ng-scope">2014 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2013" class="ng-binding ng-scope">2013 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2012" class="ng-binding ng-scope">2012 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2011" class="ng-binding ng-scope">2011 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2010" class="ng-binding ng-scope">2010 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2009" class="ng-binding ng-scope">2009 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2008" class="ng-binding ng-scope">2008 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2007" class="ng-binding ng-scope">2007 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2006" class="ng-binding ng-scope">2006 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2005" class="ng-binding ng-scope">2005 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2004" class="ng-binding ng-scope">2004 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2003" class="ng-binding ng-scope">2003 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2002" class="ng-binding ng-scope">2002 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2001" class="ng-binding ng-scope">2001 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="2000" class="ng-binding ng-scope">2000 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1999" class="ng-binding ng-scope">1999 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1998" class="ng-binding ng-scope">1998 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1997" class="ng-binding ng-scope">1997 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1996" class="ng-binding ng-scope">1996 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1995" class="ng-binding ng-scope">1995 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1994" class="ng-binding ng-scope">1994 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1993" class="ng-binding ng-scope">1993 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1992" class="ng-binding ng-scope">1992 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1991" class="ng-binding ng-scope">1991 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1990" class="ng-binding ng-scope">1990 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1989" class="ng-binding ng-scope">1989 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1988" class="ng-binding ng-scope">1988 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1987" class="ng-binding ng-scope">1987 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1986" class="ng-binding ng-scope">1986 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1985" class="ng-binding ng-scope">1985 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1984" class="ng-binding ng-scope">1984 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1983" class="ng-binding ng-scope">1983 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1982" class="ng-binding ng-scope">1982 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1981" class="ng-binding ng-scope">1981 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1980" class="ng-binding ng-scope">1980 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1979" class="ng-binding ng-scope">1979 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1978" class="ng-binding ng-scope">1978 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1977" class="ng-binding ng-scope">1977 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1976" class="ng-binding ng-scope">1976 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1975" class="ng-binding ng-scope">1975 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1974" class="ng-binding ng-scope">1974 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1973" class="ng-binding ng-scope">1973 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1972" class="ng-binding ng-scope">1972 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1971" class="ng-binding ng-scope">1971 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1970" class="ng-binding ng-scope">1970 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1969" class="ng-binding ng-scope">1969 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1968" class="ng-binding ng-scope">1968 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1967" class="ng-binding ng-scope">1967 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1966" class="ng-binding ng-scope">1966 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1965" class="ng-binding ng-scope">1965 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1964" class="ng-binding ng-scope">1964 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1963" class="ng-binding ng-scope">1963 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1962" class="ng-binding ng-scope">1962 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1961" class="ng-binding ng-scope">1961 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1960" class="ng-binding ng-scope">1960 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1959" class="ng-binding ng-scope">1959 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1958" class="ng-binding ng-scope">1958 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1957" class="ng-binding ng-scope">1957 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1956" class="ng-binding ng-scope">1956 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1955" class="ng-binding ng-scope">1955 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1954" class="ng-binding ng-scope">1954 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1953" class="ng-binding ng-scope">1953 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1952" class="ng-binding ng-scope">1952 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1951" class="ng-binding ng-scope">1951 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1950" class="ng-binding ng-scope">1950 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1949" class="ng-binding ng-scope">1949 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1948" class="ng-binding ng-scope">1948 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1947" class="ng-binding ng-scope">1947 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1946" class="ng-binding ng-scope">1946 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1945" class="ng-binding ng-scope">1945 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1944" class="ng-binding ng-scope">1944 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1943" class="ng-binding ng-scope">1943 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1942" class="ng-binding ng-scope">1942 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1941" class="ng-binding ng-scope">1941 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1940" class="ng-binding ng-scope">1940 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1939" class="ng-binding ng-scope">1939 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1938" class="ng-binding ng-scope">1938 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1937" class="ng-binding ng-scope">1937 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1936" class="ng-binding ng-scope">1936 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1935" class="ng-binding ng-scope">1935 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1934" class="ng-binding ng-scope">1934 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1933" class="ng-binding ng-scope">1933 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1932" class="ng-binding ng-scope">1932 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1931" class="ng-binding ng-scope">1931 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1930" class="ng-binding ng-scope">1930 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1929" class="ng-binding ng-scope">1929 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1928" class="ng-binding ng-scope">1928 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1927" class="ng-binding ng-scope">1927 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1926" class="ng-binding ng-scope">1926 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1925" class="ng-binding ng-scope">1925 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1924" class="ng-binding ng-scope">1924 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1923" class="ng-binding ng-scope">1923 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1922" class="ng-binding ng-scope">1922 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1921" class="ng-binding ng-scope">1921 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1920" class="ng-binding ng-scope">1920 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1919" class="ng-binding ng-scope">1919 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1918" class="ng-binding ng-scope">1918 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1917" class="ng-binding ng-scope">1917 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1916" class="ng-binding ng-scope">1916 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1915" class="ng-binding ng-scope">1915 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1914" class="ng-binding ng-scope">1914 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1913" class="ng-binding ng-scope">1913 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1912" class="ng-binding ng-scope">1912 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1911" class="ng-binding ng-scope">1911 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1910" class="ng-binding ng-scope">1910 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1909" class="ng-binding ng-scope">1909 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1908" class="ng-binding ng-scope">1908 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1907" class="ng-binding ng-scope">1907 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1906" class="ng-binding ng-scope">1906 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1905" class="ng-binding ng-scope">1905 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1904" class="ng-binding ng-scope">1904 </option><!-- end ngRepeat: item in dobyears -->
<option ng-repeat="item in dobyears" value="1903" class="ng-binding ng-scope">1903 </option><!-- end ngRepeat: item in dobyears -->
</select>
</div>
</div>
</div>
<label for="homePhone"> Home Phone <span class="asterisk">*</span> </label> <input class="form-control ng-pristine ng-untouched ng-empty ng-invalid ng-invalid-required ng-valid-maxlength" maxlength="50" ng-model="appeal.HomePhone"
placeholder="Enter your home number" required="required" type="text"> <label for="workPhone">Work Phone</label> <input class="form-control ng-pristine ng-untouched ng-valid ng-empty ng-valid-maxlength" maxlength="50" ng-model="appeal.WorkPhone"
placeholder="Enter your work number" type="text"> <label for="homeCountry"> Home Country <span class="asterisk">*</span> </label> <input class="form-control ng-pristine ng-untouched ng-empty ng-invalid ng-invalid-required ng-valid-maxlength"
maxlength="100" ng-model="appeal.HomeCountry" placeholder="Enter your home country" required="required" type="text"> <label for="emailAddress"> Email Address <span class="asterisk">*</span> </label> <input
class="form-control ng-pristine ng-untouched ng-empty ng-valid-email ng-invalid ng-invalid-required ng-valid-maxlength" maxlength="100" ng-model="appeal.EmailAddress" placeholder="Enter your email address" required="required" type="email">
<label for="authorizedRepresentative"> Authorized Representative
<a class="my-tool-tip" data-placement="right" data-toggle="tooltip" title="" data-original-title="If you are requesting that a Third Party handle your appeal, please attach a signed and completed Authorization Form."> <span class="fas fa-info-circle"></span> </a>
</label> <input class="form-control ng-pristine ng-untouched ng-valid ng-empty ng-valid-maxlength" maxlength="100" ng-model="appeal.AuthorizedRepresent" placeholder="Enter your authorized representative" type="text"> <br>
<label for="claim"> Service or Claim that was denied <span class="asterisk">*</span> </label> <input class="form-control ng-pristine ng-untouched ng-empty ng-invalid ng-invalid-required ng-valid-maxlength" maxlength="1000"
ng-model="appeal.ServiceDenied" placeholder="Enter service or claim denied" required="required" type="text"> <label for="providerName"> Provider Name <span class="asterisk">*</span> </label> <input
class="form-control ng-pristine ng-untouched ng-empty ng-invalid ng-invalid-required ng-valid-maxlength" maxlength="100" ng-model="appeal.ProviderName" placeholder="Enter provider name" required="required" type="text"> <label for="claimNumber">
Claim Number(s) <span class="asterisk">*</span> </label> <input class="form-control ng-pristine ng-untouched ng-empty ng-invalid ng-invalid-required ng-valid-maxlength" maxlength="100" ng-model="appeal.ClaimNumber"
placeholder="Enter Claim # (i.e. 214-1234567890-00)" required="required" type="text"> <label for="dateOfService"> Date of Service <span class="asterisk">*</span> </label> <input
class="appeal-DateofService hidden ng-pristine ng-untouched ng-empty ng-invalid ng-invalid-required" ng-model="appeal.DateofService" readonly="readonly" required="required" type="text">
<div class="input-group dual-date-container">
<div><input class="form-control appeal-DateofServiceRO ng-pristine ng-untouched ng-empty ng-invalid ng-invalid-required ng-valid-maxlength" disabled="disabled" maxlength="11" ng-model="appeal.DateofServiceRO" readonly="readonly"
required="required" type="text"></div>
<span class="input-group-btn" id="appealDateofServiceCal"> <a class="btn btn-primary"> <span class="fas fa-calendar"></span> </a> </span>
</div>
<br>
<label for="appealExplanation"> Please explain your appeal and your expected resolution. <span class="asterisk">*</span> </label> <textarea class="form-control ng-pristine ng-untouched ng-empty ng-invalid ng-invalid-required ng-valid-maxlength"
maxlength="1000" ng-model="appeal.ExpectedResolution" placeholder="Explain your appeal and expected resolution. (You may attach extra pages if you need more space.)" required="required"></textarea> <br>
<label for="memberSignature"> Member (or Representative) signature <span class="asterisk">*</span> </label> <input class="form-control ng-pristine ng-untouched ng-empty ng-invalid ng-invalid-required ng-valid-maxlength" maxlength="100"
ng-model="appeal.MemberSignature" placeholder="Member signature" required="required" type="text"> <label for="dateSubmitted"> Date submitted <span class="asterisk">*</span> </label> <input
class="appeal-DateSigned hidden ng-pristine ng-untouched ng-valid ng-empty" hidden="hidden" ng-model="appeal.DateSigned" readonly="readonly" type="text">
<div class="input-group dual-date-container">
<div><input class="form-control appeal-DateSignedRO ng-pristine ng-untouched ng-empty ng-invalid ng-invalid-required ng-valid-maxlength" disabled="disabled" maxlength="11" ng-model="appeal.DateSignedRO" readonly="readonly" required="required"
type="text"></div>
<span class="input-group-btn" id="appealSignCal"> <a class="btn btn-primary"> <span class="fas fa-calendar"></span> </a> </span>
</div>
<label for="relationship">Relationship to Member (if Representative)</label> <input class="form-control ng-pristine ng-untouched ng-valid ng-empty ng-valid-maxlength" maxlength="100" ng-model="appeal.RelationshipToMember"
placeholder="Relationship to member if representing" type="text"> <br>
<div id="appealUploads">
<label for="uploadFileLabel"> Upload Files
<a class="my-tool-tip" data-placement="right" data-toggle="tooltip" title="" data-original-title="Please upload medical records or any documents to help support your appeal."> <span class="fas fa-info-circle"></span> </a> </label>
<div class="form-group">
<input class="file" file-model="appeal.File1" id="appeal.File1" multiple="multiple" type="file" style="display: none;">
<div class="input-group col-xs-12"><input class="form-control input-sm fileinput" disabled="disabled" id="appeal.File1Disp" placeholder="Choose file (.pdf, .png, .jpg, .jpeg, .gif, .docx only)" type="text"> <span class="input-group-btn">
<button class="btn btn-default input-sm browse" type="button">Upload</button> <button class="btn btn-default input-sm lower" ng-click="clearInputFile('appeal.File1')" type="button">Remove</button> </span></div>
</div>
<div class="form-group">
<input class="file" file-model="appeal.File2" id="appeal.File2" multiple="multiple" type="file" style="display: none;">
<div class="input-group col-xs-12"><input class="form-control input-sm fileinput" disabled="disabled" id="appeal.File2Disp" placeholder="Choose file (.pdf, .png, .jpg, .jpeg, .gif, .docx only)" type="text"> <span class="input-group-btn">
<button class="btn btn-default input-sm browse" type="button">Upload</button> <button class="btn btn-default input-sm lower" ng-click="clearInputFile('appeal.File2')" type="button">Remove</button> </span></div>
</div>
<div class="form-group">
<input class="file" file-model="appeal.File3" id="appeal.File3" multiple="multiple" type="file" style="display: none;">
<div class="input-group col-xs-12"><input class="form-control input-sm fileinput" disabled="disabled" id="appeal.File3Disp" placeholder="Choose file (.pdf, .png, .jpg, .jpeg, .gif, .docx only)" type="text"> <span class="input-group-btn">
<button class="btn btn-default input-sm browse" type="button">Upload</button> <button class="btn btn-default input-sm lower" ng-click="clearInputFile('appeal.File3')" type="button">Remove</button> </span></div>
</div>
<div class="form-group">
<input class="file" file-model="appeal.File4" id="appeal.File4" multiple="multiple" type="file" style="display: none;">
<div class="input-group col-xs-12"><input class="form-control input-sm fileinput" disabled="disabled" id="appeal.File4Disp" placeholder="Choose file (.pdf, .png, .jpg, .jpeg, .gif, .docx only)" type="text"> <span class="input-group-btn">
<button class="btn btn-default input-sm browse" type="button">Upload</button> <button class="btn btn-default input-sm lower" ng-click="clearInputFile('appeal.File4')" type="button">Remove</button> </span></div>
</div>
<div class="form-group">
<input class="file" file-model="appeal.File5" id="appeal.File5" multiple="multiple" type="file" style="display: none;">
<div class="input-group col-xs-12"><input class="form-control input-sm fileinput" disabled="disabled" id="appeal.File5Disp" placeholder="Choose file (.pdf, .png, .jpg, .jpeg, .gif, .docx only)" type="text"> <span class="input-group-btn">
<button class="btn btn-default input-sm browse" type="button">Upload</button> <button class="btn btn-default input-sm lower" ng-click="clearInputFile('appeal.File5')" type="button">Remove</button> </span></div>
</div>
</div>
</div>
<div class="modal-footer">
<div class="pull-left"><span class="asterisk">*</span> <em>Indicates required field</em></div>
<button class="btn btn-primary" type="submit">Submit</button>
</div>
</form><form action="" onsubmit="LO.submit_chat(); return false;">
<div id="lo_chat_input" style="position:relative; width: 100%; ">
<div class="lo-fx-hr" style="height:0px; margin-bottom:0px; margin-top:0px; width:100%; border-top:1px solid #000000;border-bottom:1px solid #4f4f4f"></div>
<div style="padding:10px;"><label for="lo_chat_textarea" style="display:none">Chat Input Box</label><textarea id="lo_chat_textarea" disabled="disabled" rows="2"
style="color: black; background-color: rgb(255, 255, 255); border-radius: 5px; padding: 7px; height: auto; width: 100%; font-family: sans-serif; text-transform: none; resize: none;" dir="null" data-last-scroll-height="0"></textarea></div>
<div id="lo_chat_sound_holder" style="position:absolute; right:0px; top:-25px; width:100%;">
<div style="cursor: pointer; float:right; opacity:0.6; padding-right:10px; height:16px;" id="lo_chat_sound"><img alt="Click to mute chat sounds" src="https://d10lpsik1i8c69.cloudfront.net/graphics/sound-on-white.png"></div>
<div id="lo_chat_status" style="padding-left:10px; font-size:11px; color:#6d6d6d"></div>
<div style="clear:both;"></div>
</div>
</div>
</form>Text Content
As a Tokio Marine Group Company, WorldTrips is committed to being a Good
Company. Click here to learn more about our latest humanitarian relief efforts.
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Atlas Travel Quote Engine
* Travel Insurance
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Travel Insurance
* Travel Medical Insurance
Atlas Travel is our most popular travel medical plan for single trips abroad
* Premium Travel Medical Insurance
Atlas Premium offers the same benefits as Atlas Travel - with even higher
coverage limits
* Group Travel Medical Insurance
Atlas Group provides a 10% reduced rate for families and groups of 5+
traveling abroad
* Annual Travel Medical Insurance
Atlas MultiTrip is annual travel medical coverage for multiple trips abroad
* International Student Health Insurance
StudentSecure provides medical and emergency travel coverage to international
students
* Trip Cancellation Insurance
Atlas Journey provides U.S. residents with reimbursement for covered
cancellations, interruptions, delays, and more in the U.S. and abroad
* Trip Protection Insurance
Atlas On-The-Go provides U.S. residents with reimbursement for covered
interruptions, delays, and more in the U.S. and abroad
INSURANCE RESOURCES
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* Travel Medical Insurance - Travel Assistance Services
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* How COVID-19 Affects Your Coverage
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Additional Resources
* What Countries Require Travel Insurance for Entry?
* How Travel Advisories Affect Your Trip
* Should I Get Travel Health Insurance?
* Is Trip Cancellation Insurance Really Worth It?
* Travel Insurance vs. Travel Medical Insurance: Is There a Difference?
* What Is Emergency Medical Evacuation Coverage and Why Do I Need It?
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Our multilingual customer service representatives are available to assist you
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assisting you during a stressful travel emergency abroad.
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How To Submit A Claim
View a step-by-step guide to the claims process for members.
Learn How to Submit a Claim
About Us
WorldTrips offers a variety of travel medical and trip cancellation insurance
plans to meet the needs of individuals, groups, and organizations across the
globe.
For over 23 years, we've been on a mission to make unexpected travel mishaps and
emergencies less stressful for travelers. Our travel insurance plans can provide
you with financial compensation, access to quality healthcare, and 24/7
emergency travel assistance to guide you through the unexpected as you explore
the world.
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ACTIONS
Submit a claim or appeal for your Atlas Travel, Atlas Premium, StudentSecure,
Atlas Group, or Atlas MultiTrip plan
×
WOULD YOU LIKE TO SUBMIT A CLAIM OR AN APPEAL? PLEASE CHOOSE BELOW:
Submit Claim
Submit Appeal
Click here to learn more about our claims process.
×
SUBMIT CLAIM REQUEST
Have a question about a claim? Visit our Claims Center!
Does this claim include foreign currency? (i.e. currency other than USD) No Yes
Select Submission Type
New Claim Existing Claim
If you have not yet completed a Claimant's Statement for the condition related
to this claim, please log in to the Client Zone to complete the Claimant's
Statement electronically, or you may download it here.
Certificate Number *
Date of Birth *
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2022 2021 2020 2019 2018 2017
2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001
2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985
1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969
1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953
1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937
1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921
1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905
1904 1903
Email Address *
Claim Number
Upload Files
Note: If you are filing this claim on behalf of another person, you MUST include
the Authorization Form signed by the policyholder in order to speak with us
about the claim. Without this signed form, it is a violation of HIPAA for us to
talk with you regarding another person's insurance claim.
Upload Remove
Upload Remove
Upload Remove
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* Indicates required field
Submit
×
CLAIMANT APPEAL REQUEST FORM
DON'T HAVE AN APPEALS FORM? CLICK HERE TO DOWNLOAD OR COMPLETE THE FORM BELOW.
YOU MAY USE THIS FORM TO APPEAL A COVERAGE DECISION OR YOU CAN REQUEST AN APPEAL
BY FOLLOWING THE APPEAL PROCEDURE OUTLINED IN YOUR CERTIFICATE OF COVERAGE.
Insured Name * Mailing Address * Claimant (Patient) Name * Certificate # *
Date of Birth *
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14
15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2022 2021 2020 2019 2018 2017
2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001
2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985
1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969
1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953
1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937
1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921
1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905
1904 1903
Home Phone * Work Phone Home Country * Email Address * Authorized Representative
Service or Claim that was denied * Provider Name * Claim Number(s) * Date of
Service *
Please explain your appeal and your expected resolution. *
Member (or Representative) signature * Date submitted *
Relationship to Member (if Representative)
Upload Files
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* Indicates required field
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Submit a claim or appeal for your Atlas Journey or Atlas On-The-Go plan
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SUBMIT A CLAIM OR APPEAL FOR YOUR ATLAS JOURNEY OR ATLAS ON-THE-GO PLAN
Submit a claim
Use CPBConnect to submit a claim for your Atlas Journey or Atlas On-The-Go plan.
Send us a written appeal
Send us a letter explaining the reason you disagree with the denial of your
claim. Include your policy and/or claim number and documents that support your
claim.
Mail to:
Attention: Co-ordinated Benefit Plans, LLC
On Behalf of US Specialty Insurance Company
P.O. Box 26222
Tampa Bay, FL 33623
OR
Email to: AtlasJourneyClaims@cbpinsure.com (please include "Appeal" in the
subject line)
Call us about all other inquiries
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THANK YOU FOR CONTACTING US!
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RESOURCES
* Learn more about the claims and appeals process for travel medical insurance
plans
* Learn how to submit a trip protection insurance claim or appeal
* Visit the claims resource center to view additional claims-related resources
for travel medical plans
FREQUENTLY ASKED QUESTIONS
View FAQs related to Atlas Travel, Atlas Group, and StudentSecure travel medical
plans.
View FAQs related to Atlas Journey and Atlas On-The-Go trip protection insurance
plans.
TRAVEL ASSISTANCE SERVICES
Explore travel assistance services included with Atlas Travel, Atlas Premium,
Atlas Group, Atlas MultiTrip, and StudentSecure travel medical insurance plans.
Explore travel assistance services included with Atlas Journey and Atlas
On-The-Go trip protection insurance plans.
CLIENT ZONE AND STUDENT ZONE
Client Zone and Student Zone are our online portals for travel medical insurance
policyholders. You can use these portals to:
* Access your policy documents, including your ID card, visa
letter, and fulfillment
* Submit a claim
* Check your claim status
* Update your address
* Renew or extend your policy
* Cancel your policy
Sign in to access Client Zone and Student Zone.
DOCUMENT DOWNLOADS
Visit our Document Downloads page to view and download pdfs of brochures, claim
forms, appeal forms, and authorization/disclosure forms.
KHE2FFFYH6SP-971744701-292
WorldTrips is a service company and a member of the Tokio Marine HCC group of
companies.
WorldTrips’ Atlas Journey, Atlas Cruiser, and Atlas On-The-Go trip protection
insurance products are underwritten by Tokio Marine HCC’s U.S. Specialty
Insurance Company (USSIC). USSIC is a Texas-domiciled insurance company
operating on an admitted basis throughout the United States.
WorldTrips’ Atlas Travel Series and StudentSecure international travel medical
insurance products are underwritten by Lloyd's. WorldTrips has authority to
enter into contracts of insurance on behalf of the Lloyd's underwriting members
of Lloyd's Syndicate 4141, which is managed by HCC Underwriting Agency, Ltd.
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251 North Illinois Street Suite 600 Indianapolis, IN 46204
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INSURANCE RESOURCES
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* How COVID-19 Affects Your Coverage
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