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 * Select ... Afghanistan Albania Algeria American Minor Outlying Islands American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Aomen (Macau) Argentina Armenia Aruba Australia Austria Azerbaijan Azores Bahamas Bahrain Bangladesh Barbados Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Islands Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Canary Islands Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Coconut Islands Colombia Comoros Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Dutch Antilles East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guyana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Great Britain (United Kingdom) Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Madeira Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauretania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar (Burma) Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Islands North Korea North Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Republic of the Congo Reunion Romania Rwanda Saint Helena Saint Kitts and Nevis Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea Spain Sri Lanka St. Lucia St. Pierre and Miquelon St. Vincent and the Grenadines Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Territory of the French Southern and Antarctic Lands Thailand Togo Tokelau Islands Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Virgin Islands Uganda Ukraine United Arab Emirates United States (USA) Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Islands West Sahara Yemen Zambia Zimbabwe Specification of the location of the event Describe the place of the event (town, region) What has happened?* Select... Trip cancelled before start Trip interrupted during travels Medical claim during trip Luggage Claim Liability claim Please specify the reason * Please specify * 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 firstname.lastname@example.org. 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 email@example.com.