GENERAL CLAIM FORM Address: ACE European Group Limited, attn. Claims Department, PO Box 8664, 3009 AR Rotterdam. Tel. +31 010 289 4150 Email:
[email protected] Important: - fill in all applicable questions as completely as possible, this will avoid delays in the claim handling process. - make sure to enclose any declarations, deeds and other evidence right from the start. - make sure your answers are clearly readable, use capital letters. - also make sure to sign the form after completing it. Unsigned forms will not be handled. - return the form to the above address as soon as possible after the loss event and at the latest within the term specified in the general terms and conditions. Claim type:* o Accident/Illness o Luggage *Please tick as appropriate. 1.
o Liability o Extraordinary costs
1 Policy number: Policyholder: Surname and initial(s):
omof
Street and house number: Postcode and city: Date of birth: Telephone number
home:
work:
E-mail address: Bank account number/ IBAN:
2
Are you insured elsewhere against this damage or loss?
o yes o no
If so, Company: Policy number:
3
a. When did the damage/loss/accident/illness occur? (d-m-y):
Time (h:m):
b. Place: c. Cause: d. Circumstances: (if necessary, enclose a diagram and/or explanation of the situation on the back of this form)
To which police office was the incident reported? Police report number: Please enclose the statement made (where appropriate from the hotel, camping site, transport company, Etc)
ACE European Group Limited, Nederlands bijkantoor, Marten Meesweg 8-10, 3068 AV Rotterdam, is ingeschreven bij KvK Rotterdam onder nummer 24353249. In Nederland is zij houder van een Europees paspoort en valt zij onder het gedragstoezicht van de Autoriteit Financiële Markten (AFM). ACE European Group Limited heeft een vergunning van de Prudential Regulation Authority (PRA) in het Verenigd Koninkrijk onder nummer 202803. Statutaire zetel: 100 Leadenhall Street, London EC3A 3BP, company number 1112892.
In your opinion, can the damage or loss be recovered from a third party?
o yes o no
If so, Name: Address: Telephone: Why do you feel that the damage or loss should be recovered from that person?
Where is this person insured? Company: Policy number: What is the relationship between you and this person?
4. To be completed only in case of accident or illness. Date and circumstances of the first symptoms/signs of illness/accident?
Description of the injuries or complaints:
When was the first medical assistance provided: Name of party providing assistance: Address:
o yes o no
Are you still being treated? Name of attending: Address:
ACE European Group Limited, Nederlands bijkantoor, Marten Meesweg 8-10, 3068 AV Rotterdam, is ingeschreven bij KvK Rotterdam onder nummer 24353249. In Nederland is zij houder van een Europees paspoort en valt zij onder het gedragstoezicht van de Autoriteit Financiële Markten (AFM). ACE European Group Limited heeft een vergunning van de Prudential Regulation Authority (PRA) in het Verenigd Koninkrijk onder nummer 202803. Statutaire zetel: 100 Leadenhall Street, London EC3A 3BP, company number 1112892.
o yes o no
Where you referred to a specialist? If so, When? (d-m-y):
To whom?
o yes o no
Have you previous suffered from the same complaints? If so, on what date? Mention the first time:
Bill dated.
Name of specialist/pharmacy
Amount in foreign currency
Amount in euros
Reimbursement from state medical insurance agency or medical expenses policy
1. 2. 3. 4. 5. 6. 7. 8. 9.
NB: You should send the original bill for all costs incurred.
To be completed for every cover: Are you insured by a health care insurer? Yes / No If so, please send to ACE Europe the evidence of the Health care insurer refund.
ACE European Group Limited, Nederlands bijkantoor, Marten Meesweg 8-10, 3068 AV Rotterdam, is ingeschreven bij KvK Rotterdam onder nummer 24353249. In Nederland is zij houder van een Europees paspoort en valt zij onder het gedragstoezicht van de Autoriteit Financiële Markten (AFM). ACE European Group Limited heeft een vergunning van de Prudential Regulation Authority (PRA) in het Verenigd Koninkrijk onder nummer 202803. Statutaire zetel: 100 Leadenhall Street, London EC3A 3BP, company number 1112892.
5. To be completed only in the case of luggage claim. Details of damaged and/or lost objects.
Purchase date (d-m-y):
Purchase cost:
Estimate of damage/loss: Please enclose original purchase invoices.
o yes o no
Can the damage be repaired? If so, for how much? Where are the damaged objects?
Where and when can the damage be assessed?
6. To be completed only in the case of assistance and/or extraordinary costs. a. What do these costs consist of?
b. Why were these costs necessary? The necessity hereof should be evidenced by a doctor ‘s note.
ACE European Group Limited, Nederlands bijkantoor, Marten Meesweg 8-10, 3068 AV Rotterdam, is ingeschreven bij KvK Rotterdam onder nummer 24353249. In Nederland is zij houder van een Europees paspoort en valt zij onder het gedragstoezicht van de Autoriteit Financiële Markten (AFM). ACE European Group Limited heeft een vergunning van de Prudential Regulation Authority (PRA) in het Verenigd Koninkrijk onder nummer 202803. Statutaire zetel: 100 Leadenhall Street, London EC3A 3BP, company number 1112892.
The personal information is collected and hold by ACE European Group Limited, Marten Meesweg 8-10 in Rotterdam, for the general management of the customers relations, the sale and the commercialisation of insurances. Following the Law of protection of private life, of 8 December 1992, you have the right to consult the information concerning yourself as you have the right to correct any eventual erroneous, incomplete or without purpose piece of information relative to your person. For this, you have to send a recommended letter to the file administrator: ACE European Group Limited. The undersigned declares:
that he/she answered the above questions and provided the above particulars accurately, truthfully and to the best of his knowledge, and that he/she was not withheld any particulars relating to this claim;
that he/she submits this claim form and any additional information to the insurer for the purpose of determining the extent of the damage or loss and the entitlement to benefit;
that he/she has taken note of contents of this form.
The undersigned also hereby authorises the medical advisor of ACE Europe to obtain any desired information from attending physician(s). Said physician is also hereby authorized to provide any information relating to this claim
Place:
Date (d-m-y):
Signature:
ACE European Group Limited, Nederlands bijkantoor, Marten Meesweg 8-10, 3068 AV Rotterdam, is ingeschreven bij KvK Rotterdam onder nummer 24353249. In Nederland is zij houder van een Europees paspoort en valt zij onder het gedragstoezicht van de Autoriteit Financiële Markten (AFM). ACE European Group Limited heeft een vergunning van de Prudential Regulation Authority (PRA) in het Verenigd Koninkrijk onder nummer 202803. Statutaire zetel: 100 Leadenhall Street, London EC3A 3BP, company number 1112892.
