Cancellation Insurance Claim Mondial Assistance by alicejenny


									Dear consumer,

RE: Cancellation Insurance Claim

We are sorry that you are unable to travel on your booked trip but are pleased to be
able to offer you a claim form online.

Please print out the claim forms and ensure they are fully completed by hand, signed
and returned to us by post, together with the following documentation:

   A. A print out of your e-mail confirmation for your Insurance. Please note that we
      are unable to process your claim without this documentation.
   B. Airlines booking invoice or proof of travel and payment of trip. For internet
      bookings, this may be a print out of the e-mail confirmation.
   C. Airlines cancellation invoice. If you are travelling with a “ticket-less” airline,
      please provide written confirmation from the airline that the booking has not
      been used and no refunds issued. For non-package trips, we required written
      confirmation from the transport/accommodation providers that there is no
      refund available.
   D. Documentation in support of your need to cancel.*

*If cancellation is due to medical reasons, the medical certificate on the reverse of
the claim form must be fully completed by the usual GP of the person whose
medical condition gives rise to this claim, regardless of whether they were due to be
traveling or not. In the event of bereavement, a copy of the death certificate will
also be required.

Please note that in order for us to handle your claim as quickly and efficiently as
possible, it is you retain copies for your records. Please ensure you make it clear who
you wish any payment to be made out to, if not the claimant.

The address to return your completed claim forms and supporting documentation is
as follow:

Claim department:

Mondial Assistance
Na Maninách 7
170 00, Praha 7
Czcech Republic
                                    Claims notification - Cancellation

Personal data
                 Name:_______________________________                    Telephone:_________________


                 Street:________________________________                 E-mail:______________

                 Zip Code:______________                                 date:______________

                 Policy No.:_________________________

Period of
                 From:_______________            To:____________

Duration         Days:____________

                Policy purchase date: ____________

                Booking date: ___________________

                Date of journey: ________________ Date of return:________________

                Duration in days:________________ No. Of people insured: __________
   Medical information

   Patient: ____________________

   Date of birth:________________
   How long have you been the leading physician

   Confirmed diagnosis:

   Medical history details influencing the diagnostic:

   Was the patient hospitalized in the 12 monts before the trip? If yes, give details:

Was the patient while booking the tickets? If yes, please provide details
Was expecting a medical
                                               YES               NO

Was taking prescribed
                                               YES               NO

Was given medical
                                               YES               NO

Was aware of a sickness?                       YES               NO

Was aware of a terminal
                                               YES               NO

Physician information

Name and Surname: ________________________________


Signature: _______________________
Date: ___________________________

            Insurance benefit will be send to bank account mentioned below or send it to address of permanent
Payment     address;( we cant send you payment if will dint have this information).

               Name of bank:_____________________________________________________

               No. Of

               IBAN:_________________________________                                        SWIFT:____________________

Signature      By signing this claim form, I certify that the information herein is true and correct.

                                     ___________________________________                         ___________________
                                                   Signature                                             Date

Please, dont forget enclose the documents:
*Copy of the policy.
*Copy of the travel documents

Please, return the filled out questionnaire to:
Mondial Assistance s.r.o.
Na Maninách 7
170 00 Praha 7
Czech Republic

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