VIEWS: 9 PAGES: 5 POSTED ON: 9/24/2012
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:_________________ Surname:______________________________ Street:________________________________ E-mail:______________ City:_______________________________ Bitrh Zip Code:______________ date:______________ Policy No.:_________________________ Period of insurance From:_______________ To:____________ Duration Days:____________ Insurance information 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 procedure? Was taking prescribed YES NO medication? Was given medical YES NO examination? Was aware of a sickness? YES NO Was aware of a terminal YES NO diagnosis? Physician information Name and Surname: ________________________________ Authorisation:_____________________ Signature: _______________________ Date: ___________________________ Stamp 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). information Name of bank:_____________________________________________________ Address:__________________________________________________________ Zip Code,town:_____________________________________________ No. Of account:______________________________________________ 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
"Cancellation Insurance Claim Mondial Assistance"