I am reporting a loss and APPLYING for indemnification on the basis of the submitted data
I am reporting a loss, and am not currently APPLYING for indemnification
INSURED PERSON'S PERSONAL DATA
(the person that was involved in an accident )
Notifier’s given name and surname*
Notifier’s personal identification code*
INSURANCE CONTRACT DATA
Policy number or the policy holder’s name
(person, who concluded the policy)
Was a travel insurance policy from some other insurance undertaking in effect during the time of the event? Which one?
When and where were you planning to travel?*
Was this a business trip?
(If yes, then please mark the official title of the insured person.)
Country and location where the event took place
Date and time of the loss event*
When did the symptoms of the disease responsible for travel interruption first appear?
Has the insured person previously suffered from a similar illness? What illness and when?
In the event of an accident, specify whether the insured person was intoxicated or under the influence of narcotics at the time of the accident.
Did you contact Coris?
In the event of travel interruption I would like compensation:
This is not an incident of travel interruption
For added costs
For the costs of a cancelled trip
DETAILED DESCRIPTION OF THE EVENT
In case of illness, mark the symptoms and treatment; in case of trauma, the circumstances surrounding the event, description of the injury and treatment. In case of travel interruption mark the time, what was the reason for the change in the travel plan; in the case of damaged luggage, the date of loss and receipt of luggage.
REGISTRATION OF THE EVENT
If you have notified the airline about the incident, your travel agent, contacted the police or a medical institution to receive care, then please note the name of the institution and the time the inquiry was made.
AMOUNT OF LOSS
Have you received reimbursements related to the event? From whom and in what amount?
Detailed calculation of a compensation claim along with explanations. In the case of a luggage event, please mark the time and acquisition cost of the objects serving as the basis for the application
Total loss amount
(in euros or the settlement currency)
Given name and surname / company name of the beneficiary*
Beneficiary’s personal identification code/commercial register code
(city/rural municipality, street/road, house number, postal code)
Bank account IBAN code
Other circumstances or information, which the notifier considers important or what feedback they are awaiting
I hereby confirm that the information presented in the loss application/notice is true and, if necessary, can be certified.*
( person who submitted the loss notice or claim for compensation)
Notifier’s given name and surname
Notifier’s personal identification code
Notifier’s contact telephone
Notifier’s e-mail address
Seesam has the right to demand signed consent from the policyholder to examine the circumstances surrounding the insured event, in order to obtain information from third parties (including medical institutions, treating physicians) who are connected to the insured event