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Card Insurance claim ERV

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					  Card Insurance claim
  Bank, payment and credit cards

  Check the extent of the card's cover in the terms of insurance




  To be enclosed with the claim:

  In the event of delays to transportation or luggage
  • Receipts or verification that the trip has been paid for in accordance with the applicable terms of insurance.
  • Booking confirmation, proof of travel or similar that gives details of the travellers, departures and the total cost of the trip.
  • Proof of the delay (can be obtained from the transport company).
  • Original receipts for purchases.

  In the event of an excess claim
  • Receipts or verification that the trip has been paid for in accordance with the applicable terms of insurance.
  • Booking confirmation, proof of travel or similar that gives details of the travellers, departures and the total cost of the trip.
  • Documentation from car/rental car/home contents/household insurance indicating that compensation has been
    paid and that verifies deducted excess.
  • If the damage/injury has been reported to the police, a copy of the police report must be enclosed.
  • In the event of damage to a rental car, documents must be submitted to prove that the cost of the rental car
    has been paid in accordance with the applicable terms of insurance.

  In the event of cancellation
  • Receipts or verification that the trip has been paid for in accordance with the applicable terms of insurance.
  • Booking confirmation, proof of travel or similar that gives details of the travellers, departures and the total cost of the trip.
  • Receipts or verification of the cancellation costs.
  • Doctor's certificate stating that a doctor was consulted prior to departure, and that the illness/accidental injury
    was acute and not known about at the time of booking. Or other document stating the reason for cancellation.

  In the event of illness or accidental injury
  • Receipts or verification that the trip has been paid for in accordance with the applicable terms of insurance.
  • Booking confirmation, proof of travel or similar that gives details of the travellers, departures and the total cost of the trip.
  • Original receipts for medical costs, medication costs and/or similar.
  • Doctor's certificate.
  • For payment of death compensation, a death certificate and relatives report must be attached.
  In the event of a comprehensive insurance claim
  • Receipts or verification that the article has been paid for in accordance with the applicable terms of insurance.
  • Original purchase receipt for the damaged or lost article, and repair reports and receipts for any repairs carried out.
  • In the event of loss, a police report must be attached.
  • Warranty card.
                                                                                                                                                       3217-6-1201




                                                                                                                 ERV
                                                                                                                 Box 1
                                                                                                                 SE-172 13 Sundbyberg, SWEDEN
                                                                                                                 Visiting address: Löfströms Allé 6A
                                                                                                                 Telephone: +46 (0)770-456 900
ERV Försäkringsaktiebolag (publ), Registered office: Sundbyberg, Corporate ID no: 502005-5447                    info@erv.se | www.erv.se
Card Insurance claim
Bank, payment and credit cards

Check the extent of the card's cover in the terms of insurance


 1. Card holder's personal data
 Card number (16 figures)                                                                         Name of bank that issued the card


 Surname                                            First name                                    Personal identity number


 Address                                                         Postcode                         City


 Telephone number                                   Mobile number                                 E-mail


 Possible compensation to be paid to (name if different from above):                              Bank name


 Plusgiro/personal account                          Sort code                                     Bank account



 2. Details about the trip (to be completed even in the event of cancellation)
 Departure date                                     Date of return                                Destination


 Total cost of trip                                 Amount paid using card                        Place of purchase



 3. Details of co-insured parties affected
 Name                                             Personal identity number              Spouse      Children      Registered at card holder's address
                                                                                        Partner                   Yes        No
 Name                                             Personal identity number              Spouse      Children      Registered at card holder's address
                                                                                        Partner                   Yes        No
 Name                                             Personal identity number              Spouse      Children      Registered at card holder's address
                                                                                        Partner                   Yes        No
 Name                                             Personal identity number              Spouse      Children      Registered at card holder's address
                                                                                        Partner                   Yes        No
 Is home contents/household insurance in place?   Travel Insurance                 Insurance company              Insurance number
 Yes        No                                    Extended travel Insurance
 Has a claim been made to another insurance company?                               Insurance company              Insurance number
 Yes        No


 4. Delays to public transport
 Transport that was delayed                                                  How many hours did the delay last in total?


 When was the scheduled departure? State date and time                       When did the delayed transport depart? State date and time


 Reason for delay



 5. Luggage delay on outward journey (give details of your expenses under section 11)
 Arrival at destination. State date and time                                 When was your luggage delivered? State date and time


 Number of hours your luggage was lost   Purchase amount                     Currency                            Country



 6. Excess claim
 Excess relates to     Home contents/household insurance             Rental car insurance          Car insurance
                                                                                                   Reg.no.___________________________________
 Excess, SEK                          Insurance company                       Insurance number                   Date of damage/loss
                                                                                                                                                        3217-6-1201




 Reason for and location of damage/loss
7. Cancellation protection
Booking date                                                    Cancellation date                   State the amount refunded by the travel agency or other company


Date and location of first doctor's visit                                                        Diagnosis according to doctor's certificate


State the name and contact details of the attending doctor in Sweden




Have you suffered from the same illness previously?             If "Yes", what was the name of the attending doctor on that occasion?   Date
Yes       No
Provide a description for events that occurred in the permanent residence



8. Illness or accidental injury
Date and location of first doctor's visit                                                        Diagnosis according to doctor's certificate


State the name and contact details of the attending doctor in Sweden




Admitted to hospital?                       From date                                          To date


Are you still receiving treatment?                              Is there a risk of future problems?
Yes       No                                                    Yes          No           Don't know
Have you suffered from the same illness previously?             If "Yes", what was the name of the attending doctor on that occasion?    Date
Yes       No

9. Comprehensive insurance
Circumstances of damage/loss


Location and time


Damaged/lost article                                                                   Make/model


Purchase price                              Date of purchase                           Repair cost/current purchase price
                                                                                       for article of equal value


10. Claim for other compensation
Please provide a description of events that are not already specified on this form




11. Compensation claim




                                                                                                                                        AMOUNT
Compulsory signature
                                                                                                                                                                              3217-6 1201




I declare that the information submitted is complete and truthful.
Date                                              Signature



                                                                                                                                        ERV
                                                                                                                                        Box 1
                                                                                                                                        SE-172 13 Sundbyberg, SWEDEN
                                                                                                                                        Visiting address: Löfströms Allé 6A
                                                                                                                                        Telephone: +46 (0)770-456 900
ERV insurance Company (publ), Registered office: Sundbyberg, Corporate ID no: 502005-5447                                               info@erv.se | www.erv.se

				
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posted:9/24/2012
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