Pupil Personal Accident Report Page 4

7. Please complete the following sheet in all cases:

Date of invoice

Invoice provider

Amount of invoice

Amount being claimed

Total amount being claimed €

8. Payment details (payment will be sent to this account unless otherwise requested)

IBAN Code:

Account holder’s name:

Bank branch address:

Please return completed form to:

Allianz p.l.c.

Allianz House

Elmpark

Merrion Road

Dublin 4

Telephone: (01) 613 3559

Fax: (01) 613 4444

Email: motordamage@allianz.ie

Website:

Allianz p.l.c. is regulated by the Central Bank of Ireland. Registered in Ireland, No. 143108

78CL 02/17 KD

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Parent category: Business