Claim form luggage/luggage delay/loss/damage/theft

Claim form
luggage/luggage delay/loss/damage/theft
Please fill out all fields and forward it to Gouda Travel Insurance, A. C. Meyers Vænge 9, 2450 Copenhagen SV, Denmark or
scan it and send it as an email to [email protected] Please enclose original documentation.
Processing your claim cannot commence before we have received all relevant information.
1. Personal information
Policy No.:
Name:
Name of Company:
Gender:
Address:
Postal code:
City:
Country:
Date of birth/Social security No.:
Phone (work):
Phone (home/mobile):
E-mail:
2. Bank information
Please transfer the compensation to (please tick off):
Private bank account:
Company bank account:
Danish bank account:
Reg.no.:
Account no::
International bank account:
IBAN/Swift code:
IBAN no./Account number:
Name of bank account owner:
3. Other insurance
Insurance company (home insurance):
Policy No.:
Has the claim been reported to your home insurance company?
Are you the holder of a credit card?
If yes, which kind?
Mastercard:
Yes:
No:
Yes:
No:
Diners:
Amex:
Eurocard:
Is it a private or a corporate card?
Private:
Corporate:
Which bank has issued the card?
Type of card:
Platinum:
Other:
Card number:
Gold:
Was the card used as payment for the trip?
If yes, please enclose documentation
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Claim form
Has the claim been reported to the card company?
Other:
Yes:
No:
Yes:
No:
4. Travel information
Departure (Day/Month/Year):
Purpose of the
journey?
Business:
Country of destination:
Return date (Day/Month/Year):
Holiday/
Business:
Holiday:
Study:
Where did the incident take place (Country):
Other:
Travel agency/Tour operator:
Cancellation:
Holiday compensation:
Dental treatment:
Personal security:
Excess when renting
motor vehicles:
Other:
5. Coverage
Please tick off:
Medical/Repatriation:
Accident/Assault:
Escort and summoning: Missed departure:
Curtailment:
6. Infromation about the incident
When did the incident occur (date(month/year):
Please describe the incident as detailed as possible:
7. Illness/injury/Accident
Initial consultation (date/month/year):
Hospitalisation: from:
to:
Fit for duty (date/month/year):
Diagnosis/description of symptoms:
Have you previously suffered from the same illness/experienced the same symptoms?
Yes:
No:
Yes:
No:
If yes, when?
Did you present the European Health Insurance Card at the clinic/hospital:
If your claim concern dental treatment, please state your latest dental consultation? (date/month/year)
Contact information to your general practitioner/dentist:
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8. Expenses
(please enclose original documentation)
Expense
(Physician, medicine, transportation, food, accomodation etc.)
Expense
(local currency):
Expense
(DKK):
Have you already paid?
Yes:
No:
Yes:
No:
Yes:
No:
Yes:
No:
Yes:
No:
Yes:
No:
Total
9.Signature
I hereby give my consent allowing
• Gouda Travel Insurance to retrieve, use and release any information about me that Gouda Travel Insurance deems necessary in order to assess my
claim for compensation
• Parties from whom Gouda Travel Insurance retrieves information to release the information requested by Gouda Travel Insurance.
From/to whom may (Gouda Travel Insurance) retrieve/release information?
• Hospitals, doctors and other authorized healthcare personnel
• Public authorities, e.g. municipalities, police and the National Board of Industrial Injuries
• Insurance companies, pension funds, The Danish Centre of Health & Insurance and The Patient Compensation Association
• My employer (only exchange of certain information).
What kind of information may be exchanged?
• Health data, including information on illness and information on contacts made to the healthcare system,
• Information on social, financial and other matters
• To my employer: Name, civil registration number, and the fact that the matter concerns an insurance event
• From my employer: Work hours, absence due to illness, salary and special working conditions
The consent includes information until such time as (company name) has reached a decision regarding my claim.
Period of validity, notification etc.
The consent is valid for one year. I may, at any time, withdraw my consent and/or have any false or misleading information rectified/deleted. The
parties involved in my file will be informed of my consent.
I will be notified each time Gouda Travel Insurance retrieves information. I will be informed as to the reason for the retrieval, the nature of the
retrieved and released information, the period which it concerns, and from whom the information is retrieved.
Date:
Signature:
A.C. Meyers Vænge 9 • DK-2450 København SV • CVR-nr. 33 25 92 47 • Tlf.: (+45) 88 20 88 20 • Fax: (+45) 88 20 88 21
E-mail: [email protected] • web: gouda.dk • CVR-nr. 33 25 92 47
En del af Gjensidige • Dansk filial af Gjensidige Forsikring ASA, Norge • ORG-nr. 995 568 217
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Claim form