Insurance Claim Form
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4Insurance claim form
Emergency Assistance Abroad
Tips for completion!
please leave blank
Form to be completed in full, (including back); please print. Do not
Code
forget to enter your bank account number. Always enclose a copy of your insurance certificate.
The cover note listing the policy details may be substituted for the latter. Please enclose any
please leave blank
Dossier no.
explanatory notes on a separate sheet if there is not sufficient space on the form.
Details insured person
Name and initials
m/f E-mail
Address
IBAN
Zip code
City
In the name of
Phone number
Nationality
(day)
Phone number
Date of Birth
(evening)
(day - month - year)
Questions and answers
1
Which branch issued the insurance policy?
Name
Address
Zip code
City
2
What is the number of your insurance policy?
Number
(Please enclose copy of the policy)
3 A
Date of departure
Date
(day - month - year)
B
Duration of travel
Number of days
C
Purpose of travel/Holiday destination
4
Have you been in contact with the Emergency Centre of
Yes
No
Allianz Global Assistance, and if so, on which date?
Date
(day - month - year)
Dossier number
Questions 5-9 must only be answered in case of recall or premature termination of the trip
5 A
Please explain as briefly as possible what exactly occurred and who were involved
(Please indicate family relationship, if necessary on a separate sheet of paper)
B
Name and address of the person under question 5 A?
Name and initials
Date of Birth
(day - month - year)
Address
Zip code
City
C
Who is your General Practitioner (GP)?
Name and initials
Phone number
Address
Zip code
City
D
Who was the physician providing treatment?
Name and initials
Phone number
Address
Zip code
City
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Parent category: Business