Insurance Claim Form (Page 4 of 4) in pdf

Insurance Claim Form Page 4

Specifications

Description

€

Amount

Paid

Yes

Additional notes

(if necessary sketch of the situation)

Personal details entered on this form and any details which may be submitted later may be included in the insured persons administration of Allianz Global Assistance and in a central information

system for insurance companies active in the Netherlands. Please contact Allianz Global Assistance if you have any questions and regarding the data protection rules which apply tot these records.

The undersigned declares • to have answered and provided the above questions and details accurately, truthfully and to the best of his/her knowledge, and not to have withheld any information

relating to the loss or damage • to give permission herewith (in so far this is necessary) to the medical advisor(s) of Allianz Global Assistance to provide any relevant details to the medical advisor of

Allianz Global Assistance in relation to the reason and background in case of medical treatment, admission to hospital and/or repatriation • to submit this claim form and details still to be provided

to Allianz Global Assistance partially for the purpose of determination of the amount of the damages and entitlement to payment • to have taken note of the contents of this form • to be familiar

with the condition that any entitlement to payment becomes invalid upon submission of incorrect/false details. Signing of this form signifies that you transfer entitlement to payments based on

any insurance policy elsewhere to Allianz Global Assistance.

Date

Signature

AWP P&C S.A. - Dutch Branch

Poeldijkstraat 4, 1059 VM Amsterdam

Tel: +31 (0)20 561 87 30

schade@allianz-assistance.nl

Chamber of Commerce

PO Box 9444, 1006 AK Amsterdam

Fax: +31 (0)20 561 87 87

Amsterdam nr 33094603