Home Claim form Continuous Travel and Cancellation

Claim form Continuous Travel and Cancellation

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Claims number(Required)

Type of insurance(Required)

Policy number(Required)

Name(Required)

First name Insert Surname

Address(Required)

Street + house number City of Postal code

Phone number(Required)

Email address(Required)

Bank account number(Required)

I have checked the above information and modified if necessary.(Required)

Yes

General

When did the incident occur?(Required)

DD dash MM dash YYYYY

Date of departure(Required)

DD dash MM dash YYYYY

Duration of trip(Required)

Travel purpose/holiday destination(Required)

Are you entitled to deduct VAT?(Required)

Yes

Do you possibly have coverage for this loss on another insurance policy?(Required)

Yes

With which insurer?(Required)

Under which policy number?(Required)

What happened?

What happened?(Required)

I cancelled my trip

My luggage is stolen / missing / damaged

I incurred medical expenses

I had to cut my trip short early

I arrived at my vacation destination later

I have had bad luck with my means of transportation

Other

Please indicate here in as much detail as possible what happened?(Required)

On what date did this occur?(Required)

DD dash MM dash YYYYY

What costs have you incurred or will you incur?(Required)

What was damaged or what did you have to miss?(Required)

Cancellation

Was there any premature return?(Required)

Yes

How much was the travel or rental fee?(Required)

With which travel agency or tour company did you book the trip?(Required)

Did you request (partial) refund of the travel or rental fee?(Required)

Yes

When did you do this?(Required)

DD dash MM dash YYYYY

What event caused the trip to be canceled?(Required)

By death

Due to an accident / serious illness

Due to the failure of the motor vehicle

Due to another cause

Please describe here in as much detail as possible by what reason you canceled the trip?(Required)

Premature return

Have the expenses incurred been discussed with the alarm center?(Required)

Yes

When did the return trip take place?(Required)

DD dash MM dash YYYYY

Did you still return to the vacation destination?(Required)

Yes

When did you return to your vacation destination?(Required)

DD dash MM dash YYYYY

How much was the travel or rental fee?(Required)

With which travel agency or tour company did you book the trip?(Required)

Did you request (partial) refund of the travel or rental fee?(Required)

Yes

When did you do this?(Required)

DD dash MM dash YYYYY

What event forced you to return early?(Required)

By death

Due to an illness or serious accident

Due to breakdown of the motor vehicle

By another event

Please describe here in as much detail as possible the event that forced you to return prematurely?(Required)

Did you call the emergency center?(Required)

Yes

Motor Vehicle

What is the type, make, year and registration number of the motor vehicle?(Required)

What was the cause of the failure of the motor vehicle (also description of damage)?(Required)

How many days did the repair take?(Required)

Was or will another motor vehicle be rented for the motor vehicle?(Required)

Did you call the emergency center?(Required)

Yes

Serious illness

Was there an accident or illness?(Required)

Accident

Disease

What disease is involved?(Required)

Is the person among the insured?(Required)

Yes

Since when has the person been suffering from this disease?(Required)

What is the name, first name, date of birth and your relationship to the person?(Required)

Was there hospitalization?(Required)

Yes

Serious illness while traveling

Did this illness occur during the trip?(Required)

Yes

Has the alarm center been activated?(Required)

Yes

How many medical expenses were incurred?(Required)

Was there hospitalization?(Required)

Yes

How many days did the hospitalization last?(Required)

Was the family physician consulted?(Required)

Yes

When was the family physician consulted?(Required)

DD dash MM dash YYYYY

What is the name and address of the primary care physician?(Required)

Were you referred to a specialist?(Required)

Yes

What is the name and address of the specialist?(Required)

Have the medical expenses been submitted to the health insurance company?(Required)

Yes

Accident

Please provide a detailed description of the accident here?(Required)

What does the injury consist of?(Required)

Is the victim among the insured?(Required)

Yes

What (family) relationship exists to insured person?(Required)

Please here name, first name and date of birth of the person to whom the said incident happened:(Required)

Did the accident occur during the trip?(Required)

Yes

Accident while traveling

Has the alarm center been activated?(Required)

Yes

Was there any admission to the hospital(Required)

Yes

How many days did you spend in the hospital(Required)

Was the family physician consulted?(Required)

Yes

What is the name and address of the primary care physician?(Required)

Were you referred to a specialist?(Required)

Yes

What is the name and address of the specialist?(Required)

How many medical expenses were incurred?(Required)

Have the medical expenses been submitted to the health insurance company?(Required)

Yes

Do you have any damage to luggage as a result of the accident?(Required)

Yes

Death

Name of the person who died(Required)

First name Insert Surname

Date of birth of the person who died(Required)

DD dash MM dash YYYYY

Address and residence of the person who died(Required)

Street + house number City of Postal code

When did the person die?(Required)

DD dash MM dash YYYYY

What (family) relationship exists to you?(Required)

Theft or damage

What event caused damage?(Required)

Theft/missing

By another event

Did you incur any additional expenses as a result of this event?(Required)

Yes

Luggage theft or loss

Did the damage occur during air travel or at the airport?(Required)

Yes

Was a Property Irregularity Report (P.I.R.) prepared?(Required)

Yes

Third choice

Have you filed a report with any agency?(Required)

Yes

Which agency did you report to?(Required)

If you did not file a tax return, please state the reason here?(Required)

Is there theft from the car?(Required)

Yes

Where and why were the goods in the car?(Required)

How many items were stolen or missing?(Required)

1 item

2 objects

3 objects

4 objects

5 objects

more than 5 items

Please indicate here in as much detail as possible what happened?(Required)