Travel insurance




INSURED PERSON'S PERSONAL DATA
(the person that was involved in an accident )


Notifier’s given name and surname*

Notifier’s personal identification code*
Contact telephone*
E-mail address*

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?

TRAVEL


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.)

LOSS EVENT


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:

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
(month/year).*
Total loss amount
(in euros or the settlement currency)

BENEFICIARY


Given name and surname / company name of the beneficiary*

Beneficiary’s personal identification code/commercial register code
Address
(city/rural municipality, street/road, house number, postal code)

Bank account IBAN code

ADDITIONAL INFORMATION


Other circumstances or information, which the notifier considers important or what feedback they are awaiting

Notifier
( 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