travel insurance claim application

TRAVEL INSURANCE CLAIM APPLICATION
APPLICANT
First name and surname
ID code
Postal address
Telephone number s
E - m ail
INSURED PERSON (complete if the applicant is not the insured person)
First name and surname
ID code
Postal address
Telephone number s
E - m ail
CO-INSURED
First name and surname
ID code
First name and surname
ID code
CREDIT
TRAVELCARD
INSURANCE
Travel
insurance
American
Express® Gold
offered via Swedbank
Internet bank
American Express® GoldAmerican American
Express®Express®
PlatinumPlatinum
Star t date of trip
Visa/MasterCard Gold
Visa Platinum
Business Gold
E n d d a t e o f t r ip
Route of trip
LOSS EVENT
D a t e o f t h e even t
T im e
Place of the event
Loss event
Brief description of the loss event
Death as a result of an accident
Cancellation of trip
Disability as a result of an accident
Interruption of trip
Medical treatment expenses
Missing the means of transport
Services covered by medical treatment expenses
Transportation of the ill or injured person to the place of treatment
Loss of luggage
Expenses incurred in repatriation of the ill or injured person
Delay of luggage
Legal costs
Expenses incurred in repatriation of the deceased
Liability insurance
Repatriation of a child
Casco Insurance of rental car
Travel expenses of the person close to the insured person
Expenses incurred in prolonging the trip due to an illness
Brief description of the loss event
SWEDBANK P&C INSURANCE AS
Liivalaia 12, 15039 Tallinn
Tel 888 2111
Faks 888 2112
[email protected] www.swedbank.ee
The following were informed of the loss event:
Swedbank P&C Insurance AS
Customer service of
American Express®
SOS International a/s
Police
Airline
Other
Have you taken additional travel insurance from another insurance company?
no
yes
Please indicate the insurance company and sum insured
Have you received indemnities or refunds in association with loss events?
no
yes
no
yes
no
yes
Please indicate who paid the money and in what amount
Please indicate this person
INDEMNITY
Type of expense receipt and issuer
(e.g. Flight ticket – Estonian Air)
Details of expense receipt
(e.g. Flight from Tallinn to Riga)
Amount of reimbursement
being applied for
SUM:
Please pay the indemnity
current account number
The applicant gives the insurance company the right to process his or her client data (incl. personal data and delicate personal data) by submitting
this application. The insurance company shall process the applicant’s client data pursuant to the procedure for processing client data principles of
processing client data in the Estonian companies of Swedbank. The applicant represents and warrants that they have reviewed said procedure and
they are aware of the circumstance that the relevant procedure is available on the internet at www.swedbank.ee and in the insurer’s offices.
Signature of the applicant