Claim Notification Form

Policy Holder Information

Gender: MaleFemale

First Name: *

Surname: *

E-mail:

Date of birth: *

Country code (autofill):

Phone number: *

Home adress: *

Postcode: *

City: *

Country: *

Claimant

Type:

Gender:MaleFemale

First Name: *

Surname: *

Phone number: *

E-mail:

Insurance Details

Country: *

Name of the insurance company: *

Name of the policy: *

Policy number: *

Trip Information

Trip start: *

Trip end: *

Destination country: *

Purpose of tip:

Number of travel companions (same policy):

Temporary place of stay: *

Nature of Request

Type:

Financial Details

Beneficiary:

PDF, TXT, image (max 2MB per 1 file)

Contact Person

Type:

Gender:MaleFemale

First Name: *

Surname: *

Phone number: *

E-mail:

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