Online claim contact form
Claiment
Type:
Policy Holder
Work Company
Relative
Travel Agency
Other
Gender:
Male
Female
Trip Information
Trip start (required):
Trip end (required):
Purpose of tip:
Leisure
Business
Number of travel companions (same policy):
1
2
3
4
5
Temporary place of stay (required):
Insurance Details
Policy Holder Information
Gender:
Male
Female
Nature of Request
Type:
Medical Assistance
Luggage
Trip Cancellation
Reimbursement
Other
Financial Details
Beneficiary:
Claimant
Policy Holder
PDF, TXT, image (max size 2MB)
(required)
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