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 Location Postal code

Phone number(Required)

Email address(Required)

Bank account number(Required)

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

Yes

No

General

When did the incident occur?(Required)

Date of departure(Required)

Duration of trip(Required)

Travel purpose/holiday destination(Required)

Are you entitled to deduct VAT?(Required)

Yes

No

Do you have coverage for this damage under another insurance policy?(Required)

Yes

No

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

Would you please describe what happened in as much detail as possible?(Required)

On what date did this occur?(Required)

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

What has been damaged or what have you had to miss out on?(Required)

Cancellation

Was there any premature return?(Required)

Yes

No

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

Which travel agency or tour operator did you book your trip with?(Required)

Have you requested a (partial) refund of the travel or rental costs?(Required)

Yes

No

When did you do this?(Required)

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 in as much detail as possible why you canceled your trip.(Required)

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)

Have you contacted the emergency services?(Required)

Yes

No

Serious illness

Was there an accident or illness?(Required)

Accident

Disease

What disease is involved?(Required)

Is the person among the insured?(Required)

Yes

No

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

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

Was there hospitalization?(Required)

Yes

No

Accident

Would you like to provide a detailed description of the accident here?(Required)

What does the injury consist of?(Required)

Is the victim among the insured?(Required)

Yes

No

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

No

Death

Name of the person who died(Required)

First name Insert Surname

Date of birth of the person who died(Required)

Address and residence of the person who died(Required)

Street + house number Location Postal code

When did the person die?(Required)

What is your (family) relationship?(Required)

Theft or damage

What event caused damage?(Required)

Theft/missing

By another event

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

Yes

No

Later at vacation destination

What was the reason for your late arrival at the vacation destination?(Required)

flight delay

Another reason

How many hours were you delayed?(Required)

What airline was flown with?(Required)

Could you please explain in as much detail as possible the reason for the delay?(Required)

Which travel agency or tour operator did you book your trip with?(Required)

What is the travel or rental fee?(Required)

Did this event result in additional special expenses for you?(Required)

Yes

No

Special additional costs

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

Yes

No

How much extra did you have to spend?(Required)

Are your additional costs listed here?(Required)

Have you also contacted the emergency center about the additional costs incurred?(Required)

Yes

No

Closing

Please describe in as much detail as possible the damage you have suffered and what happened.(Required)

Do you have any questions or comments? You can ask/submit them here:(Required)

If available, add the following documents. The booking confirmation for the trip. The invoice for the cancellation costs. In the event of theft or loss, a copy of your police report. Purchase receipts for the damaged or lost items.(Required)

Drag files here or

Max file size: 2 MB.

Signature(Required)

CAPTCHA

Claim form Continuous Travel and Cancellation

General

What happened?

Cancellation

Premature return

Motor Vehicle

Serious illness

Serious illness while traveling

Accident

Accident while traveling

Death

Theft or damage

Luggage theft or loss

Luggage damage

Later at vacation destination

Special additional costs

Closing

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