Claim form - Business trip

Transcription

1 Claim form - Business trip Illness, injury, accident, repatriation, personal assistance Policyholder Claim no. (policy no. and date of claim) Company contact person Company name VAT no. Company address Postal code City Company address Company telephone no. Insured First name Last (family) name Date of birth (dd/mm/yy) Gender (M/F) Male Female Address Postal code City Country Telephone no. address Name of treating physician Address Postal code City Country Information about the trip Purpose of trip Holiday Business Combined holiday/business Travelling period to/from home country: Date of departure (dd/mm/yy): Travel destination (city, country) Date of return (dd/mm/yy): Choose coverage Illness/injury/death Compassionate emergency visit Replacement employee Death caused by accident Compassionate emergency repatriation Medical accompaniment (medical escort) Permanent disablement caused by injury Dental injury 1/6 Claim Form Business Trip Illness, injury, accident, repatriation, personal assistance Tryg Klausdalsbrovej Ballerup Tryg Forsikring A/S VAT no

2 Information about the claim Diagnosis: Date of first symptom (dd/mm/yy): Have you previously suffered from the same symptoms/illness? When did the illness/injury occur? If yes: Please describe the illness/injury in detail: When did you first see a doctor? If hospitalised, please state: Admission date (dd/mm/yy): Discharge date (dd/mm/yy): Have you been in contact with Tryg s emergency centre? If yes, please state the reference number: Did the illness/injury lead to changes in the itinerary? Did you resume the trip? If yes, please state new itinerary: If yes, when? 2/6 Claim Form Business Trip Illness, injury, accident, repatriation, personal assistance

3 Compensation Medical expenses Has the invoice been settled? Compassionate emergency repatriation Expenses (transport) Compassionate emergency visit Expenses (hotel, meals, transport) Medical accompaniment (medical escort) Expenses (hotel, meals, transport) Replacement employee Expenses (hotel, meals, transport) 3/6 Claim Form Business Trip Illness, injury, accident, repatriation, personal assistance

4 Other insurance Do you have a European Health Insurance Card? If yes, have you received a refund? Do you have another travel insurance? - If yes, please fill in the following: Policy no./card no If yes, have you received compensation? Insurance company/name of credit card provider Have you reported the incident to any of the above? If you have received compensation: : : Payment Name of the recipient of the reimbursement First name Last (family) name Address Postal code City Country Banking details Danish account Account holder Name of the bank Sort code Account number International account Account holder Name of the bank Sort code Account number BIC/SWIFT code/aba no. IBAN 4/6 Claim Form Business Trip Illness, injury, accident, repatriation, personal assistance

5 Signature I solemnly declare that all information in this claim form is true. Date Signature In order for us to process your claim the best way possible, it is important that you complete the entire claim form and send us the necessary documentation. Along with the claim form, please enclose: Original invoice for accommodation and transport (ticket) Medical report and original invoices from the attending physician/hospital abroad Original invoices for other expenses Detailed invoice for telephone calls to/from Tryg Documentation for the reason for repatriation Copy of the European Health Insurance Card Please send the claim form and documents to: Tryg - Expatriation and Business Travel Claims, E43 Klausdalsbrovej Ballerup - Denmark If you have any questions about this claim form, please do not hesitate to contact us on phone no.: or by [email protected] ERH 021 (01.13) 5/6 Claim Form Business Trip Illness, injury, accident, repatriation, personal assistance

6 Consent to the obtaining and disclosure of information Insurance event The reason why you must give your consent When you claim compensation from your insurance company, you are obliged to give your insurance company all available and relevant information in accordance with the Danish Insurance Contracts Act. Therefore, you have to give us all information that may be important for the assessment of your case and the size of the compensation payment. Your doctor and others may disclose information With your consent, your doctor can disclose information about your health under the Danish Health Act. Insurance companies and others may also disclose information about you with your consent, under other legislation. Disclosure of information We also need your consent to be able to disclose necessary information and to pass on the completed and signed claim form in order to claim reimbursement of our expenses from other parties in the matter (recourse and double insurance). You can always withdraw your consent Your consent is valid for one year after you have given it. A copy of this consent will be given to everyone we want to obtain information from. You can always withdraw your consent, if you have second thoughts about it. Declaration of consent I consent to all relevant information in connection with this claim being obtained by Tryg Forsikring for instance information about illness, information about my health, including contact with the healthcare system etc. Information may be obtained from general practitioners, hospitals and other relevant parts of the healthcare system as well as from other insurance companies, the Public Tourist Health Insurance, SOS International A/S, other departments at Tryg Forsikring, tour operators and airlines. The above information that may be obtained includes information up to and including the time where Tryg Forsikring has assessed my claim for compensation, if any. In order for Tryg Forsikring to be able to claim reimbursement of expenses from other parties in the matter (recourse and double insurance), I consent to relevant information about this claim being disclosed by Tryg and to this signed claim form being passed on to other insurance companies, tour operators, airlines, SOS International A/S, the Danish National Agency for Patients' Rights and Complaints (European Health Insurance Card/the blue card) and other departments at Tryg Forsikring. A copy of this consent will be given to the doctor, hospital etc. which is asked to provide information to Tryg Forsikring and to the parties from whom Tryg Forsikring claims reimbursement of expenses. Date Signature Civil registration number ERH 021 (01.13) 6/6 Claim Form Business Trip Illness, injury, accident, repatriation, personal assistance