Insurance Claim Form – Notification of loss under insurance of

insurance
Insurance Claim Form
Notification of loss under insurance of costs of resignation from travel/aeroplane ticket
For the purpose of quick and efficient examination of the claim, please complete the form below accurately and send directly to the address of the loss
adjuster acting on behalf of AXA TUiR S.A.
Please attach the following to the form:
Correspondence address:
1. participation agreement/confirmation of reservation of the ticket or accommodation
Inter Partner Assistance Polska S.A.
2. payment confirmation of participation agreement/ticket
3. the travel agent’s statement confirming how much money was refunded to the customer
ul. Prosta 68
4. the carrier’s confirmation in the case of a ticket cancellation
00-838 Warszawa
5. original receipts and proofs of payment for return transport in the case of early return
tel. +48 22 575 90 80
6.documents confirming the necessity of cancelling participation in the event
(medical documentation, certificate issued by the police or other relevant body)
7. the travel agent’s confirmation that participation in the event has been cancelled
8. a photocopy of your identity document (identity card or passport)
A. GENERAL INFORMATION
1.
Name and surname of the claimant
(or legal guardian)
2. Contact tel. no. 3. Name and surname of the insured person
4.Address
Town/City
Post code
Street
/
House number/flat number
Post code
Street
/
House number/flat number
Contact tel. no. 5. Correspondence address
Town/City
6. E-mail address
Do you consent to correspondence being sent to you by e-mail?
yes
no
7. PESEL personal electronic identity number*
8.Number of the Beneficiary’s bank account
to which indemnity should be paid
9. Name of the bank
10. Name and surname of the account holder
11. Instructions on the method of payment of indemnity Town/City
postal order (please state the residence address if different from the one given above)
Post code
Street
/
House number/flat number
12. Policy number/travel reservation number
13. Date and place where the policy was taken out (applies to individual policies)
14. Name of the travel agent – organizer (applies to group policies under agreements with tour operators)
15. Name, phone number and address of the travel agent where the event/ticket was purchased, name of the contact person
AXA Towarzystwo Ubezpieczeń i Reasekuracji S.A., ul. Chłodna 51, 00-867 Warszawa, tel. +48 22 555 00 00, fax +48 22 555 05 00, www.axa.pl
Register Authority: Sąd Rejonowy dla m.st. Warszawy, XII Wydział Gospodarczy KRS; National Court Register No. KRS 38616; Tax Identification No. NIP 521-10-36-865; Share capital: PLN 86 521 500 – paid in full
16. How was the reservation made/agreement signed:
personally (or through other persons) at the travel agent’s
via the Internet (with an agreement sent by post)
over the phone (with an agreement sent by post)
in another manner (how?)
17. Information on all the persons who cancelled their trip:
Name and surname
Date of birth
D D M M Y Y Y Y
D D M M Y Y Y Y
D D M M Y Y Y Y
D D M M Y Y Y Y
D D M M Y Y Y Y
B. INFORMATION ON THE TRAVEL
Date of reservation of the trip/ticket
Planned start date of the trip
D D M M Y Y Y Y
Planned end date of the trip
D D M M Y Y Y Y
D D M M Y Y Y Y
Name of the carrier (in the case of ticket cancellation)
C. INFORMATION ON THE LOSS
1. The reasons for resignation/early return
a)
medical reasons
sudden illness
b)
loss in property
theft and burglary
2. Was the occurrence caused by:
an offence
suicide
death
fire
physical labour
accident
premature childbirth
other (specify)
playing a competitive sport
other reasons (specify)
3.Information on the person because of whom the loss under the insurance of costs of resignation occurred
Is the Insured a travel companion?
Name and surname:
Is the Insured a relative?
Name and surname:
yes
no
yes
no
Specify the relationship (please attach a copy of the document confirming the blood relationship)
4. Date of the event because of which the travel had to be cancelled/the return had to be early
Date of loss
Date of notifying the organizer/carrier of the resignation
D D M M Y Y Y Y
D D M M Y Y Y Y
a) travel cancellation fees
amount deducted by the organizer/carrier
currency
amount
b) e
arly return fees
costs of purchasing a return ticket
currency
amount
D. ATTACHMENTS
Confirmation of policy or insurance taken out with the tour operator
yes
no
Agreement-notification or a plane ticket
yes
no
Print-out of cancellation fees/event or ticket cancellation form
yes
no
Copy of death certificate
yes
no
Medical form
yes
no
Police report on the offence or accident
yes
no
Other documents
yes
no
2
E. DECLARATIONS
I acknowledge that my personal data will be processed by AXA TUiR S.A. with its registered office in Warsaw, for the purpose of settling the loss being
claimed.
I authorise the Company to acquire any medical information, save for results of genetic examinations, concerning the state of my health, from any
doctor who has treated me or provided me with medical advice, and also in all medical centres and healthcare institutions where I received medical
assistance. Further, I agree to any information on the state of my health being made available to the Company by doctors, medical centres and
healthcare institutions.
I authorise the Company to obtain information in court, at the public prosecutor’s office, and from the police and other bodies and institutions in
connection with the accident or event that is the basis for establishing the Company’s liability.
D D M M Y Y Y Y
Date
Signature of the Insured or attorney-in-fact
I hereby confirm that the information given above is true and I am aware that certifying an untruth or giving false information may result in my being held
criminally liable and may result in a refusal to pay indemnity.
D D M M Y Y Y Y
Date
Signature of the person reporting the loss
We wish to inform you that providing your personal data is voluntary but necessary for the insurance contract to be implemented and the claim to be examined (the sole purpose
– data processing). The data administrator is AXA Towarzystwo Ubezpieczeń i Reasekuracji S.A. with its registered office in Warsaw, 00-867, ul. Chłodna 51. The data subject is
authorised to inspect and amend his/her personal data and to lodge a written and substantiated demand that his/her personal data no longer be processed in light of his/her
special situation, and to object to the processing of his/her personal data.
* Applies to Polish citizens only.
3311016_EN
If you need help in filling in this form, please call +48 22 575 90 80 or write to [email protected].
Medical Form
Dear Doctor,
Following receipt of notification of a loss under the insurance of travel cancellation costs, please complete the present form. Under to the terms and
conditions of the insurance contract, the Insured is required to release the doctors who treated him/her from doctor-patient privilege.
Yours faithfully,
AXA TUiR S.A. and Inter Partner Assistance Polska S.A.
1.Information on the Patient
Name and surname
Date of birth:
D D M M Y Y Y Y
Address
Post code
Town/City
Street
/
House number/flat number
2. Medical diagnosis
3. Date of sickness/accident
D D M M Y Y Y Y
4. Date of first consultation relating to the sickness/accident
D D M M Y Y Y Y
5. Was the travel cancellation justified from the medical point of view?
yes
no
6.
Was the patient treated for the said illness in the period before the reservation of the travel?
If so, when?
yes
no
yes
no
D D M M Y Y Y Y
7.
Were there any medical contraindications to travel at the time of the reservation was made?
If so, please specify.
8.
Date on which the patient was informed that
he/she must cancel the travel:
D D M M Y Y Y Y
8.1. P
lease state the date on which the first symptoms indicating
that the patient would not be able to travel appeared:
D D M M Y Y Y Y
10. W
as a sick note issued to the patient?
If so, for what period?
D D M M Y Y Y Y
Place
Date
Doctor’s signature and stamp
AXA Towarzystwo Ubezpieczeń i Reasekuracji S.A., ul. Chłodna 51, 00-867 Warszawa, tel. +48 22 555 00 00, fax +48 22 555 05 00, www.axa.pl
Register Authority: Sąd Rejonowy dla m.st. Warszawy, XII Wydział Gospodarczy KRS; National Court Register No. KRS 38616; Tax Identification No. NIP 521-10-36-865; Share capital: PLN 86 521 500 – paid in full
3311016_EN
9. Name the contraindications preventing the patient from travelling: