Travel claim notice Details of the person reporting the event First name of the person reporting * Last name of the person reporting * Personal ID code * E-mail address * Mobile number * The person reporting is the person incurring the damages * Yes No Injured party First name* Surname * Personal ID code * E-mail address Telephone Add another person incurring the damages Policy number or the name of the policyholder * Details of the event Start of the trip * End date of the trip Itinerary Please add all transfers and destinations Date when event occurred * If the exact date is unknown, please mark down the date of becoming aware of the event Time of the event In the case of illness or trauma mark down the time of the first symptoms/injuries Country where the event happened * Specification of the location of the event Describe the place of the event (town, region) Event description *Describe, in detail, the reasons, events and consequences of the insured event To whom was the event reported? The police The hotel The travel agency The transport company Other Please specify * List of expenses incurred Description of costs Sum Currency unit +Additional line Additional information Include additional information about the event here. In the event of loss or damage to the luggage, please indicate the time, place and the price of the purchase. If the luggage/bag is damaged, please indicate name and dimensions of the luggage/bag. Has the insured person concluded a similar insurance contract with any other company? * Yes No Don’t know Please state the insurance company * Has the insured person received an indemnity or repayment in relation to this case? * Yes No Don’t know Please specify * File upload (total maximum 30Mb) File upload Here you can add documentation that is associated with the case. For example, pictures, plane tickets, expense documents, medical documentation, etc – Remove fie + Add more files I request an indemnity for the incurred damages * Yes No Estimated damage in euros Name of beneficiary Bank account number * I hereby confirm that all data above is right and complete. I know that if I knowingly submit wrong data, then insurer has the right to decrease compensation or refuse to pay compensation completely. I agree that insurer has the right to request additional information concerning the claim from persons that possess it. Your claim report is sent to ERGO claims' processing department.We thank you in advance for your patience as there may be more letters, calls and inquiries than normally, so it may take longer than usually to respond and handle the claim. In case of additional questions please send email to address email@example.com. There was an error during data sending.We are sorry. There was an error during data transfer. Please send your request directly to the email firstname.lastname@example.org.