CLAIM REPORT FORM CLAIM NUMBER: Claim Report Date / /

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1 CLAIM NUMBER: Mil, --/--/2010 CLAIM REPORT FORM Claim Report Date Claimant surname Claimant name Telephone Number COMPLETE IN CAPITAL LETTERS Europäische Reiseversicherung AG Registered Office Rosenheimer Straße 116 D München Branch Office and General Agent for Italy Via Fra Riccardo Pampuri 9/A I Milano address INSURANCE COVER INVOLVED (on the basis of which a refund is requested) Trip cancellation (any reason) Trip curtailment or early return (any reason) Medical expenses and Assistance (illness, accident, hospitalisation, check-ups, medicines etc.) Baggage and Purchase of essential items Travel Accidents (death or disability) Third Party Public Liability Other damages Claim Call Center Tel option 2 Fax Mondays to Thursdays, 9.30am-12.30pm, 2.30pm -5.30pm; Fridays 9.30am-12.30pm Certified Post Internet POLICY RELATED DATA Member of ETI Group European Travel Insurance Group POLICY NUMBER (or tariff code) Tax code, VAT and Milan Company Register POLICY PURCHASE CHANNEL (enter name of Tour Operator, Agency, web site etc.) INSURED PARTY DATA Surname Name Address number AER Company Capital: 84,973,478 ISVAP Insurance and Reinsurance Company register no. I Company authorised to exercise insurance activities in Italy in accordance with 'art. 23 of L.D. No. 209 of 7/9/2005 n. 209 (ISVAP communication no 5832 dated 27/9/2007). Post Code Residence Date of Birth National Insurance No Telephone Number address Europäische Reiseversicherung AG General Agent for Italy ACCIDENT CLAIM FORM - Page 1/5

2 PERSONAL DATA OF INSURED PARTIES WITH SAME POLICY SURNAME NAME DATE OF BIRTH TRIP RELATED DATA TOURIST SERVICE PROVIDER (enter name of Tour Operator, Agency, web site etc. or indicate ORGANISED BY YOU) BOOKING DATE TRIP START DATE TRIP END DATE DESTINATION / ITINERARY ACTUAL DEPARTURE ACTUAL RETURN TYPE OF TRIP/TRANSPORT Hotel/Resort Holiday Home Own Home Plane Ship Coach Train Own means of Transport Other CLAIM RELATED DATA ACCIDENT EVENT DATE HAVE YOU ALREADY CONTACTED THE CLAIMS DEPARTMENT? YES NO IF YES, WHEN? HAVE YOU ALREADY BEEN ASSISTED? YES NO Europäische Reiseversicherung AG General Agent for Italy ACCIDENT CLAIM FORM - Page 2/5

3 BRIEF DESCRIPTION OF THE EVENT (cause, events, symptoms, dates etc.) DOCUMENTS TO ENCLOSE IN THE EVENT OF CANCELLATION and TRIP CURTAILMENT 3 Invoice for cancelling trip/services booked indicating penalty applied 4 Invoice applying penalty resulting from trip curtailment 5 Medical certificates if cancellation is due to illness/injury/disability etc. 6 Death certificate if cancellation is due to the insured s death or related persons 7 Documents relating to cause of cancellation if not due to illness IN THE EVENT OF REFUND OF MEDICAL EXPENSES and ASSISTANCE 3 Medical documents issued by the hospital 4 Invoices/receipts relating to expenses sustained 5 Payment receipts 6 Any third party refunds IN THE EVENT OF BAGGAGE and PURCHASE OF ESSENTIAL ITEMS 3 Document reporting loss to the competent authorities 4 Original P.I.R. * 5 Lost baggage document 6 Baggage return receipt 7 Receipts for items stolen/lost 8 Receipts for essential items purchased * Property Irregularity Report: Lost or damaged baggage report issued by Airport Authorities IN THE EVENT OF ACCIDENTS DURING THE TRIP (death/disability) 3 Any reports issued by the police 4 Medical documents issued by the hospital/a&e 5 Invoices/receipts relating to expenses sustained Europäische Reiseversicherung AG General Agent for Italy ACCIDENT CLAIM FORM - Page 3/5

4 IN THE EVENT OF PUBLIC LIABILITY 3 Personal data of injured party 4 Any witness reports 5 Any documents relating to damage caused 6 Amount of damage caused 7 Police report IN THE EVENT OF REFUND FOR OTHER EVENTS OR DAMAGE SUFFERED 3 Any documents proving damage suffered and request for a refund LIST OF EXPENSES INCURRED AND RELATIVE RECEIPTS Please enclose originals of all receipts, medical prescriptions, medical or hospital invoices or any other documents proving the costs sustained (in the event of partial refund from other insurance companies please enclose a copy of the relative notice) LIST OF EXPENSES INCURRED TYPE OF RECEIPT (invoices, receipts, travel agreements etc.) ISSUE DATE COST IN FOREIGN CURRENCY EXCHANGE RATE APPLIED COST IN EUROS DIRECT PAYMENT YES NO Europäische Reiseversicherung AG General Agent for Italy ACCIDENT CLAIM FORM - Page 4/5

5 ANY OTHER INSURANCE COVER Indicate any other insurance policies covering the event reported here. INSURANCE COMPANY POLICY NUMBER Documents to enclose in the event of other insurance cover: 1 Insurance certificate of Company involved 2 Policy conditions of Company involved BANK DETAILS Name of account holder (parent/guardian if a minor) Bank name/city IBAN code BIC/SWIFT Code CONSENT I the undersigned expressly authorise the Claims Department of Inter Partner Assistance and ERV Italia - Europäische Reiseversicherung AG General Agent for Italy to obtain all information necessary as regards illnesses and/or disabilities caused by an accident, both past and present, from me, doctors, hospitals and local medical centres thus releasing them from their professional secret. Moreover, I do authorise them to obtain any other information necessary to manage the claim reported herein. DATE SIGNATURE DECLARATION I the undersigned hereby declare that the information provided is true and correct to the best of my knowledge and belief and am aware that providing any false or misleading information could result in the loss of insurance cover. DATE SIGNATURE COMPLETE AND RETURN VIA OR REGISTERED LETTER A/R: ERV Italia - Europäische Reiseversicherung AG General Agent for Italy CLAIMS DEPARTMENT Via Fra R. Pampuri Milano Italia PEC certified post: Europäische Reiseversicherung AG General Agent for Italy ACCIDENT CLAIM FORM - Page 5/5

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