Claims notification Travel indemnity insurance

Transcription

1 Claims notification Travel indemnity insurance To process the claim on behalf of the relevant insurer we need some further information. We therefore ask you to complete this form, sign it and send it back to us as soon as possible. Thank you Certificate of insurance number: (please quote in all correspondence) 1. Policyholder: Title: Mr Ms Company Street: Post code: Town/city: address: Tel. (mobile/cell): 2. Person who caused the loss: Title: Mr Ms Street: Post code: Town/city: Travel into / out of the country: (please enclose appropriate evidence (copy of visa, etc.)) on: Return scheduled for: address: Tel. (mobil): Occupation/ most recent job: 3. Person suffering the loss: Title: Mr Ms Street: Post code: Town/city: Driving license: Date of issue: Issuing agency: address: Tel. (mobile/cell): The person suffering the loss and the policyholder or person insured are connected by a Family relationship, namely: living arrangement under the same roof employment / work / other contractual relationship, namely: Injury: yes no 4. Additional party / witness (please note any further parties/witnesses on a separate sheet): Title: Mr Ms Street: Post code: Town/city: address: Tel. (mobile/cell): Page 1 from 4 FBVNHV leistung@care-concept.de Internet:

2 Claims notification Travel indemnity insurance 5. Details of the accident Date of loss/injury: Time: Where the damage/loss occured: Details recorded by the Office/station: police: yes no 6. Outline description/sketch: (please also enclose any photos) File reference: 7. Further details where one or more vehicles were involved: Vehicle A Vehicle B Type (e.g. car, truck, motorcycle) Manufacturer Model Registration Number year Damage Prior damage Insured with Leased vehicle yes no The vehicle is a business asset yes no Vehicle was parked Was moving off Stopped Was leaving a car park, property, etc. Was turning into a car park property, etc. Was braking Was approaching from behind Was travelling parallel in another lane Changed lanes Turned off to the right Turned off to the left Was overtaking Was travelling in the opposite direction Was reversing Did not give way (e.g. at traffic lights) Speed prior to collision yes no Driver under the influence of alcohol yes no yes no Left the scene of the accident yes no 8. Supplementary details Claims have already been made: (Please enclose correspondence) Yes, in the amount of EUR no I consider the claims justified: Yes, because no, because Any compensation is to be paid: Policyholder / account BIC: Claimant / account BIC: Entitlement to reclaim input VAT (value-added tax): : IBAN: IBAN: by the policyholder yes no By the claimant yes no Page 2 from 4 FBVNHV leistung@care-concept.de Internet:

3 Claims notification Travel indemnity insurance 9. Information in cases of damage to property What was damaged? Nature and extent of Type (e.g. scratch, scorch mark): damage: Extent (e.g. scratches everywhere, small mark/stain) The item was bought: on approximately: Price (approx.): EUR (enclose proof of purchase, if available) Value of damage: approximately.: Repair possible: yes no (if yes, please enclose estimate) Inspection: An inspection was carried out by The item is available for inspection at the premises of The item was in the possession of you / your family / business employees under the following arrangement: Was the damage incurred by the item as a result of an activity The object is covered under another valid policy: Rental/hire: yes no Loan : yes no yes (e.g. repair, etc.), namely Glass Fire Mains water Home contents TPFT- Fully comprehensive Other (e.g. mobile/cell phone policy) Lease: yes no Safekeeping: yes no no with: Policy number: 10. Details of personal injuries Name, address, date of birth of the injured person: Nature and extent of injury: Nature (e.g. bruising) Street: Post code: Town/city: Extent (e.g. all over the body) The injured person is employed by (employer): Street: Post code: Town/city: Company (where applicable): Inpatient treatment: yes, from: to unknown Attending physician: Initial treatment was undertaken by: Subsequent treatment was undertaken: Reported to a yes, to name: no File reference: Page 3 from 4 FBVNHV leistung@care-concept.de Internet:

4 Claims notification Travel indemnity insurance Important notes on the consequences of breaches of obligations following the claims event: Cautionary guidance pursuant to Sect. 28 IV of the German Insurance Policies Act (VVG) Dear Customer, once the claims event has occurred, we need your help Duty to provide information and clarification On the basis of the matters of contractual agreement reached with you, the Insurer, represented by Care Concept AG, may require you to provide any and every item of information that is necessary in order to verify the claims event or the extent of its obligation to provide indemnity (duty to provide information) and, by means of providing all detail helpful towards clarifying the facts of the matter (duty to provide clarification), to enable it to examine its obligation to provide indemnity. The Insurer may also require you to provide it with evidence / documents where this may be reasonably demanded of you. No obligation to provide indemnity Where, contrary to the matters of contractual agreement, you wilfully provide false account or no account whatsoever or where you wilfully fail to provide the Insurer, represented by, with the required evidence / documents, you will not forfeit your entire claim, but the Insurer may curtail its indemnity in keeping with the gravity of such failing on your part. No curtailment shall occur where you provide evidence to the effect that you have not violated the obligation through gross negligence. Despite breach of your obligations to provide information or clarification or to procure evidence / documents, the Insurer shall nonetheless remain obliged to provide indemnity to the extent that you provide evidence to the effect that the wilful or grossly negligent breach of obligation was not causal either to ascertainment of the claims event or to the extent of the obligation to provide indemnity. Where you are in fraudulent breach of your obligations to provide information or clarification or to procure evidence / documents, the Insurer shall in all cases be free of any obligation to provide indemnity. End of cautionary guidance N.B.: Where the right to contractual indemnity is the entitlement not of you, but of a third party, such third party shall likewise be obliged to provide information and clarification and to procure documentary evidence. Final declarations I confirm that my above statements are truthful and complete. I am aware that incorrect and / or incomplete information may result in loss of insurance cover. I have taken note of the above statements pursuant to Sect. 28 Para. 4 of VVG regarding the consequences of breaches of obligations following occurrence of the claims event. I am aware that I am also responsible for the accuracy and completeness of details provided by me even where I have not completed this form personally. I assign to the Insurer providing insurance cover my claims and entitlements, to the value of the indemnity provided by such Insurer, against any party causing the accident / liable party / other party under an obligation to provide indemnity. I hereby give my consent that the insurer providing the cover and the administrator may collect, store, use and transfer between them personal data pertaining to me to such extent as may be required for purposes of checking the application and of establishing, executing or terminating the insurance policies and of invoicing commission payments. (Place, Date (Signature of policyholder) and (Signature insured person or his/her legal representative) Page 4 from 4 FBVNHV leistung@care-concept.de Internet:

5 To process the claim on behalf of the relevant insurer we need some further information. We therefore ask you to complete this form, sign it and send it back to us as soon as possible. Thank you! Certificate of insurance number: please quote in all correspondence) 1. Claimant: Title: Mr Ms Company Street: Post code: Town/city: Qualified occupation: Most recent job/position: address: Tel. (mobile/cell): Bank details: Account holder: Firstname: BIC/sort code IBAN / account no..: 2. Person who caused the loss (policyholder / insured person): Title: Mr Ms Street: Post code: Town/city: address: Tel. (mobile/cell): Insured person: Street: House number: Post code: Town/city: 3. Other party to the accident / witness (please note any further parties/witnesses on a separate sheet): Title: Mr Ms Street: Post code: Town/city: address: Tel. (mobile/cell): 4. Details of the accident Date of damage/ Uhrzeit: loss: Where the damage/ loss occurred: Recorded by: Office/station: File reference: Street: Post code / Town/city: 5. Outline description / sketch (please also enclose any photos) Page 1 of leistung@care-concept.de Internet:

6 6. Further details where one or more vehicles were involved Vehicle A: Vehicle B: Type (e.g. car, truck, motorcycle) Make & model Vehicle was parked Was moving off Stopped Was leaving a car park, property, etc. Was turning into a car park property, etc. Was breaking Was approaching from behind Was travelling parallel in another lane Changed lanes Turned off to the right Turned off to the left Was overtaking Was travelling in the opposite direction Was reversing Did not give way (e.g. at traffic lights) Speed prior to collision yes no Driver under the influence of alcohol yes no yes no Left the scene of the accident yes no 7. Details in the case of damage to one or more objects: What was damaged: Who is the owner of this object: Is the object a business asset: yes no Is it possible to reclaim input VAT (valueadded yes no tax): Nature and extent of damage: When / at what price was the object acquired: Estimated cost of restoration/repair: Estimated duration of repair work: The object is available for viewing at the premises of: The object has been viewed by: Previous damage: (if available please enclose proof of purchase) Date (approx.): Price (approx.): (please attach cost estimate) approx. approx. days Name / Name / Number: Extent: Page 2 of leistung@care-concept.de Internet:

7 The object is covered under a valid policy (tick type of policy): Insurer: glass fire Policy no.: mains water home contents third party, fire and theft fully comprehensive other, e.g. mobile / cell phone policy; as follows: Claim/loss has already been reported to this insurer: yes no Additional information in the case of car damage Type of vehicle: Make & model: Year of manufacture: Mileage (km): Registration number: Number of previous owners: The car is insured as follows: Third party cover: yes no Fully comprehensive: yes (policy excess ) no TP Fire & Theft: yes (policy excess ) no Vehicle recovery service: Insured with: Policy no.: Where a total loss (write-off) situation does not apply, we recommend the repair work be put in hand immediately, bearing in mind your statutory duty to minimise the loss. The liable party will not cover a loss arising due to any delay in issuing a repair instruction. When issuing instructions, the repairer's attention should be drawn to the fact that the invoice is to be issued in accordance with the work value lists published by the manufacturers. Page 3 of leistung@care-concept.de Internet:

8 8. Details where someone has been injured (where someone has sustained injury, please also complete and sign the statement of confidentiality waiver at the bottom of this form): Injured person: Street: House number: Current contact details: Post code: Town/city: Country: Mobile/cell Employer: Qualified occupation: Most recent job: Self-employed: yes, as no Annual income: gross: net Marital status: Dependents Number: Ages: (e.g. children): Health insurance scheme: state health insurance private health insurance private supplementary cover Name of relevant pension scheme agency: Was this a workplace / commuting accident: Policy number: Policy number: yes Name of relevant Statutory Institute for Work Accident Insurance & Prevention: no File reference: Page 4 of leistung@care-concept.de Internet:

9 9. Additional details where someone has been injured: Nature and extent of injuries sustained: The injuries have healed completely yes no Inpatient treatment for injury: yes, from to no Hospital providing treatment: Outpatient treatment for injury: yes, from to no Attending physicians: Other treatment at/by: Sick leave: yes, from to no The injury was sustained despite yes no protective features: The following protective feature was in use: Safety belt Helmet (motorcycle, bicycle or crash helmet) special protective clothing (e.g. motorcycle clothes, work shoes) Important notes: I confirm that my above statements are truthful and complete. I am aware that I am also responsible for the accuracy and completeness of details provided by me even where I have not completed this form personally. (Place, Date (signature of the claimant or his/her legal representative) Page 5 of leistung@care-concept.de Internet:

10 Consent to the collection of medical information Statement of confidentiality waiver Consent to the collection and use of medical information and statement of confidentiality waiver 1. Collection, storage, use and disclosure of personal data: I hereby give my consent that the insurer providing the cover (hereinafter referred to as "Insurer") and the administrator Care Concept AG (hereinafter referred to as "Care Concept") may collect, store, use and transfer between them personal data pertaining to me to such extent as may be required for purposes of checking the application and of establishing, executing or terminating the insurance policies and of invoicing commission payments. 2. Collection, storage and use of medical data: In order to be allowed to collect and use your medical data for this benefit application and in connection with the policy, the Insurer and Care Concept require your consent under data protection legislation and your confidentiality waivers in order to be able to collect your medical data from holders, such as doctors, who are under a duty of confidentiality, and in order - where necessary - to pass your medical data and other data falling under the protection of Sect. 203 of the German Penal Code to other recipients. The following statements of consent and confidentiality waiver are indispensable for purposes of checking the application and for establishment, execution or termination of your insurance policy. If you choose not to make them, it will generally not be possible to set up the policy. I hereby give my consent that the Insurer and Concept may collect, store, use and transfer between them medical data disclosed by me in this claim notification and at any time in the future to such extent as may be necessary for purposes of checking the application and of establishing, executing or terminating this insurance policy. 3. Disclosure of your medical data to entities not pertaining to the Insurer The Insurer shall subject downstream entities to a contractual duty to observe data protection and data security regulations. 3.1 Disclosure of data for medical assessment purposes Where medical assessors have to be brought in for purposes of assessing the risks to be insured and of examining the obligation to provide benefits, the Insurer and Care Concept require your consent and confidentiality waiver where this involves disclosure of your medical data and other data subject to protection under Sect. 203 of the German Penal Code. You will be informed of each instance in which data is passed on. I hereby give my consent that the Insurer and Care Concept, in its administrative capacity, may pass on my medical data to medical assessors where necessary for risk assessment purposes or for purposes of examining the obligation to provide benefits and where my medical data are used by such recipient(s) in accordance with the intended purpose and where the outcomes are passed back to the relevant Insurer. With regard to my medical data and other data protected under Sect. 203 of the German Penal Code, I hereby release persons working for Care Concept and the Insurer examining my potential entitlements and the assessors from their duties of confidentiality. 3.2 Disclosure of data where functions as assigned to other entities Certain tasks, such as claims processing, telephone customer service and the emergency hotline, which may involve collection, processing or use of your data, are not handled by the Insurer and Care Concept in-house, but are rather assigned to other entities. Where your data falling under the protection of Sect. 203 of the German Penal Code is passed on, Care Concept and the relevant Insurer require a confidentiality waiver from you for these entities. I hereby give my consent that the Insurer and CareConcept may pass my medical data to D+S communications center management GmbH, Hamburg H.B.C. Hanse Betreuungscenter GmbH, Hamburg Roland Assistance GmbH, Cologne Insurance Warehouse Gesellschaft für Finanzdienstleistungen GmbH, Hamburg and that the medical data will be collected, processed and used there for the stated purposes to the same extent as the Insurer and Care Concept would be permitted so to do. To the extent necessary, I hereby release the staff of the Insurer and of Care Concept and of other entities from their duties of confidentiality with respect to disclosure of medical data and other data subject to the protection of Sect. 203 of the German Penal Code. The list does not purport to be exhaustive as changes may have occurred in the meantime. A current list may be obtained by written request to Care Concept. Page 6 of leistung@care-concept.de Internet:

11 3.3. Disclosure of data to reinsurers In order to safeguard the meeting of your claims and entitlements, the Insurer and Care Concept avail themselves of reinsurance arrangements which assume the risk either in part or in whole. Information concerning your existing policies may be disclosed to reinsurers for purposes of settling commission payments and benefit payouts and for purposes of invoicing reinsurance arrangements and also in connection with risk and claims assessment. Your personal data will be used by the reinsurers for the aforementioned purposes only. You will be informed by the Insurer and by Care Concept regarding disclosure of your medical data to reinsurers. I hereby give my consent to disclosure of my medical data - where necessary - to reinsurers and to their use thereof for the purposes mentioned. To the extent necessary, I hereby release the staff acting for the Insurer and for Care Concept from their duties of confidentiality with respect to the medical data and other data subject to the protection of Sect. 203 of the German Penal Code. (Place and date) (signature of the claimant or his/her legal representative) Page 7 of leistung@care-concept.de Internet:

12 Statement of confidentiality waiver Name of the person making the statement: D.O.B.: Date of the accident the of first symptoms of medical disorder: Certificate of insurance number: in: Post code, town/city: in: I am aware that, for purposes of assessing its duty to pay insurance benefits, the relevant Insurer, represented by Care Concept AG, shall examine the information provided by me in support of my claims/entitlements or transpiring from documents submitted by me (e.g. certifications, attestations, etc.) or transpiring from communications which I have caused to be sent by a hospital or medical practitioner. For this purpose, I release Title Name Street, House no. Post code Town/city from his/her duty of doctor-patient confidentiality This confidentiality waiver also applies to authorities - with the exception of social security institutions - and also to staff of other accident, health and life insurers who may be asked to provide details of relevant existing insurance arrangements involving them. I am issuing this statement on behalf of who is not in a position to judge the implications of this statement. (In cases of legal guardianship, please enclose a copy of the certificate of appointment / the guardian ID document) (Place, Date) (signature of the claimant or his/her legal representative) Page 8 of leistung@care-concept.de Internet: