Travel claim notice

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

Policy number or the name of the policyholder *

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 *

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.

Details of the person reporting the event

Injured party

Details of the event

File upload (total maximum 30Mb)

ERGO Life insurance+