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NOTIFICARE DAUN EFECTE PERSONALE / BANI PERSONAL EFFECTS / MONEY CLAIM FORM

V mulumim pentru notificarea daunei. V rugm s completai acest formular i s-l transmitei ctre: Thank you for notifying us of you claim. Please complete this claim form and return it to: SPECIALTY CLAIMS SERVICES PO BOX 51541 LONDON SE1 0XU Dac avei nevoie de ajutor pentru completare, v rugm contactai-ne la: If you need any help in completing this form, please contact us on: +44 (0)20 7902 7410

Detaliile pgubitului Claimant details


Formul Adresare / Title Numele complet / Full Name Data naterii / Date of birth Ocupaie / Occupation ara de domiciliu / Ususal Country of Domicile

Adresa pgubitului (claimant address):

Cod potal (postcode): Telefon (telephone): E-mail: (adresa de email poate fi utilizat pentru coresponden dac este menionat / e-mail may be used for correspondence if stated) Detaliile Asigurrii Insurance details Numr certificat (Certificate number): Compania de Asigurare (Insurance Company): Adresa brokerului (Address of Broker):

NOTIFICARE DAUN EFECTE PERSONALE / BANI PERSONAL EFFECTS / MONEY CLAIM FORM

Detaliile cltoriei Travel Details Destinaie (travel destination): ara (country): Staiune (resort): Hotel (hotel): Data plecrii (departure date): Scopul Cltoriei (purpose of trip): Detaliile daunei Claim details Data incidentului (date of incident): / Ora incidentului (time of incident): : Locaia incidentului (place of incident): / AM PM Daun pentru (claim for): Pierderi (loss) Pagube (damage) Amnare (delay) / / Data revenirii (return date): Recreere (Pleasure) / /

Afaceri (Business)

Circumstanele producerii daunei (full circumstances surrounding the claim):

Data la care a ajuns bagajul dvs. dac este o daun pentru ntrzierea bagajelor: (the date on which your luggage arrived if claiming for baggage delay) A fost incidentul raportat Poliiei, Turoperatorului sau Hotelului? (has the incident been reported to the Police, Holiday Rep or Hotel?) DA (YES)

NU (NO)

A fost incidentul raportat companiei aeriene implicate? DA (YES) NU (NO) (has the incident been reported to the relevant airline?) Dac ai bifat nu la intrebrile de mai sus, v rugm motivai (if no to any of the above, please state reason why):

Ai mai raportat alte daune pentru bunurile personale, anterior acestei daune? DA (YES) (have you made any personal property claims prior to this claim?) Dac da, v rugm detaliai (if yes, please give details):

NU (NO)

Deinei o asigurare de locuin toate riscurile/bunuri? (do you hold any household all risk/contents insurance?) Dac da, v rugm detaliai (if yes, please give details):

DA (YES)

NU (NO)

NOTIFICARE DAUN EFECTE PERSONALE / BANI PERSONAL EFFECTS / MONEY CLAIM FORM

Deinei asigurare de cltorie asociat contului dvs. bancar? (do you hold any travel insurance with your current bank account?) Dac da, v rugm detaliai (if yes, please give details):

DA (YES)

NU (NO)

V-ai folosit cardul de credit pentru a achita total sau parial cltoria? DA (YES) (did you use your credit card to pay for all or part of your trip?) Dac da, v rugm s ne transmitei extrasul de cont aferent acestei tranzacii. (if yes, please provide the relevant card statement showing the transaction). Ai depus o cerere de despgubire la orice alt asigurtor / instituie? (have you submitted a claim to any other insurer / authority?) Dac da, v rugm detaliai (if yes, please give details): DA (YES)

NU (NO)

NU (NO)

Dac dauna dumneavoastr va fi acceptat, v rugm s menionai ctre cine va trebui pltit despgubirea: (if your claim is agreed, please state to whom settlement should be made): Numele Beneficiarului majuscule: (print payee name) Valuta preferat: (preferred currency)

Declaraie Declaration n deplin cunotin de cauz, declar c toate detaliile furnizate n acest formular sunt adevrate i corecte. n cazul n care o ter parte este rspunztoare pentru pierderile/pagubele produse, toate drepturile n aceast privin sunt subrogate Serviciului Daune pentru soluionarea daunei. Dac exist acoperire furnizat prin alt poli, mi dau acordul pentru stabilirea contribuiei de ctre asigurtori. Sunt contient c unele informaii furnizate de mine vor fi puse la dispoziia altor asigurtori pentru a fi folosite la subscriere sau la gestionarea daunelor. I declare that to the best of my knowledge all particulars contained in this form are true and correct. In the event of a third party being liable for loss/damage all rights in this matter are subrogated to Specialty Claims Service on settlement of the claim. If cover exists under any other policy, I give my authority for contribution to be sought from their insurers. I understand that some of the information provided will be made available to other insurers for underwriting or claims handling purposes. Semntura: (signed) Data: (date) / /

NOTIFICARE DAUN EFECTE PERSONALE / BANI PERSONAL EFFECTS / MONEY CLAIM FORM Detaliile obiectelor n daun Details of Items being claimed
Descrierea complet a obiectelor declarate n daun (full description of the item being claimed) Magazinul i locaia de unde au fost achiziionate (shop/store and location where purchased) Data / anul achiziionrii (date/year of purchase) Dovada proprietii ataat ? (Evidence of Ownership enclosed?) Iniialele proprietarilor (initials of Owners) Preul iniial pltit (original price paid) Suma cerut inclusiv moneda (amount claimed including currency) PENTRU UZUL BIROULUI DE DAUNE (OFFICE USE ONLY)

NOTIFICARE DAUN EFECTE PERSONALE / BANI PERSONAL EFFECTS / MONEY CLAIM FORM Instruciuni Guidance Notes Urmtoarele documente sunt necesare pentru a putea procesa cererea dvs. (the following documentation must be provided in order for your claim to be processed) Document (item) Factura original de rezervare care v-a fost trimis la momentul rezervrii cltoriei (your original booking invoice which is sent to you at the time of booking your trip) Aceasta confirm datele de nceput i sfrit ale cltoriei (this confirms your outward and return travel dates) Polia de asigurare a cltoriei original, cu perioada acoperit i prima pltit (your original travel insurance schedule showing the dates of cover and premium paid) Dac avei o poli anual, atunci va fi acceptat o copie a acesteia (if you have an annual policy then a fotocopy will be accepted) Ataat (enclosed)

Pentru daunele privind furtul/pierderile (in respect of loss/theft claims) Raportul ctre Poliie/Turoperator/Hotel (police/holiday rep/hotel report) Raport Neregulariti Bagaje furnizat de compania aerian, dac este cazul (Property Irregularity Report given to you by the airline, if applicable) V rugm anexai cel puin unul din urmtoarele documente pt fiecare obiect n daun: (please include at least one of the following for each item claimed) Chitane / Bonuri (purchase receipts) Extras de cont/card ce demonstreaz achiziionarea/retragerea banilor necesari (bank/card statements showing purchases/withdrawals) Manuale de utilizare, Certificate de garanie / conformitate (user manuals, warranty and/or guarantee slips) Evalurile emise anterior datei incidentului (valuations issued prior to the date of loss) Fotografii ale dvs cu bunurile solicitate (photographs of you with the items being claimed) Chitanele pentru schimburile valutare (banii personali) (currency conversion slips personal money)

NOTIFICARE DAUN EFECTE PERSONALE / BANI PERSONAL EFFECTS / MONEY CLAIM FORM

Pentru daunele privind obiectele deteriorate (in respect of damaged articles being claimed) Raport Neregulariti Bagaje furnizat de compania aerian, dac este cazul (Property Irregularity Report given to you by the airline, if applicable) Deviz estimativ reparaii sau confirmarea c reparaia este imposibil (estimate of repair or confirmation that items are damaged beyond repair) orice tarif implicat este responsabilitatea asiguratului (Any charge is the responsibility of the claimant) V rugm anexai cel putin unul din urmtoarele documente pt fiecare obiect n daun: (please include at least one of the following for each item claimed) Chitane / Bonuri (purchase receipts) Extras de cont/card ce demonstreaz achiziionarea/retragerea banilor necesari (bank/card statements showing purchases/withdrawals) Manuale de utilizare, Certificate de garanie / conformitate (user manuals, warranty and/or guarantee slips)

n cazul bagajelor ntarziate (In respect of baggage delay claims) Chitanele obiectelor adiionale achiziionate ca urmare a ntrzierii (receipts for the additional items purchased as a result of the delay) Raport Neregulariti Bagaje furnizat de compania aerian, dac este cazul (Property Irregularity Report given to you by the airline, if applicable) Confirmarea primit de la compania aerian cu privire la perioada ntrzierii (confirmation from the airline of the length of the delay)

Asigurarea bunurilor din locuin Household insurance Pentru a minimiza efectul solicitrilor frauduloase de daun, Asiguratorii i furnizeaz informaii cu privire la daunele dvs.. Asigurtorii contribuie la soluionarea daunelor altor companii de asigurare. Aceasta distribuie costurile i ajut la meninerea primelor la un nivel redus. Aceste operaiuni se fectueaz n concordan cu Acordul de Contribuie ABI i dac beneficiai de un bonus pentru lipsa daunelor acesta nu va fi afectat. To minimize the effect of fraudulent claims Insurers share information about your claims. Insurers contribute to the settlement of each others claims. This shares the costs and helps to keep your premiums down. This is done in accordance with the ABI Contribution Agreement and if you have a no claims discount this should not be affected.

NOTIFICARE DAUN PIERDEREA MBARCRII / NTRZIEREA CLTORIEI TRAVEL DELAY / MISSED DEPARTURE CLAIM FORM
V mulumim pentru notificarea daunei. V rugm s completai acest formular i s-l transmitei ctre: Thank you for notifying us of you claim. Please complete this claim form and return it to: SPECIALTY CLAIMS SERVICES PO BOX 51541 LONDON SE1 0XU Dac avei nevoie de ajutor pentru completare, v rugm contactai-ne la: If you need any help in completing this form, please contact us on: +44 (0)20 7902 7410

Detaliile pgubitului Claimant details


Formul Adresare / Title Numele complet / Full Name Data naterii / Date of birth Ocupaie / Occupation ara de domiciliu / Usual Country of Domicile

Adresa pgubitului (claimant address):

Cod potal (postcode): Telefon (telephone): E-mail: (adresa de email poate fi utilizat pentru coresponden dac este menionat / e-mail may be used for correspondence if stated) Detaliile Asigurrii Insurance details Numr certificat (Certificate number): Compania de Asigurare (Insurance Company): Adresa brokerului (Address of Broker):

NOTIFICARE DAUN PIERDEREA MBARCRII / NTRZIEREA CLTORIEI TRAVEL DELAY / MISSED DEPARTURE CLAIM FORM

Detaliile cltoriei Travel Details Destinaie (travel destination): ara (country): Staiune (resort): Hotel (hotel): Data plecrii (departure date): Scopul Cltoriei (purpose of trip): Detaliile daunei Claim details NTRZIEREA CLTORIEI TRAVEL DELAY Motivele ntrzierii (reason for the delay): / / Data revenirii (return date): Recreere (Pleasure) / /

Afaceri (Business)

Punctul de plecare unde s-a produs ntrzierea : (departure point where delay occurred) Punctul de sosire: (arrival point) Data i ora programate pentru plecare: (scheduled date and time of departure) Numrul zborului / navei: (flight / ferry number) Numrul companiei aeriene / navei: (airline / ferry number) Data i ora reale ale plecrii: (actual date and time of departure) Numrul zborului / navei: (flight / ferry number) Numrul companiei aeriene / navei: (airline / ferry number) Numrul de ore de ntrziere: (number of hours delay) Ai primit orice restituiri / variante alternative de la operatorul cltoriei? (have you received any refund/alternative booking from the travel operator?) Dac da, v rugm detaliai (if yes, plese give details): DA (YES) NU (NO) / / : AM PM

AM PM

NOTIFICARE DAUN PIERDEREA MBARCRII / NTRZIEREA CLTORIEI TRAVEL DELAY / MISSED DEPARTURE CLAIM FORM

PIERDEREA MBARCRII MISSED DEPARTURE otivele pierderii mbarcrii (reason for the missed departure):

Aeroportul / portul de plecare: (departure Airport/Port for your trip) Punctul de pierdere a conexiunii: (point of connection failure) Metoda de transport: (method of transport) Mijloacele implicate pentru reluarea cltoriei: (means employed to rejoin trip) Cheltuieli adiionale solicitate ca daun: (additional expenses being claimed)

Ai solicitat despgubiri / ai transmis o plngere, sau ai primit orice restituri de la operator? (have you made a claim/complaint, or received any refund from the operator?) Dac da, v rugm s ne transmitei copia corespondenei. (if yes, please provide a copy of any correspondence)

DA (YES) NU (NO)

Dac dauna dumneavoastr va fi acceptat, v rugm s menionai ctre cine va trebui pltit despgubirea: (if your claim is agreed, please state to whom settlement should be made): Numele Beneficiarului majuscule: (print payee name) Valuta preferat: (preferred currency)

Declaraie Declaration n deplin cunotin de cauz, declar c toate detaliile furnizate n acest formular sunt adevrate i corecte. n cazul n care o ter parte este rspunztoare pentru pierderile/pagubele produse, toate drepturile n aceast privin sunt subrogate Serviciului Daune pentru soluionarea daunei. Dac exist acoperire furnizat prin alt poli, mi dau acordul pentru stabilirea contribuiei de ctre asigurtori. Sunt contient c unele informaii furnizate de mine vor fi puse la dispoziia altor asigurtori pentru a fi folosite la subscriere sau la gestionarea daunelor. I declare that to the best of my knowledge all particulars contained in this form are true and correct. In the event of a third party being liable for loss/damage all rights in this matter are subrogated to Specialty Claims Service on settlement of the claim. If cover exists under any other policy, I give my authority for contribution to be sought from their insurers. I understand that some of the information provided will be made available to other insurers for underwriting or claims handling purposes. Semntura: (signed) Data: (date) / /

NOTIFICARE DAUN PIERDEREA MBARCRII / NTRZIEREA CLTORIEI TRAVEL DELAY / MISSED DEPARTURE CLAIM FORM

Instruciuni Guidance Notes Urmtoarele documente sunt necesare pentru a putea procesa cererea dvs. (the following documentation must be provided in order for your claim to be processed) Document (item) Factura original de rezervare care v-a fost trimis la momentul rezervrii cltoriei (your original booking invoice which is sent to you at the time of booking your trip) Polia de asigurare a cltoriei original, cu perioada acoperit i prima pltit (your original travel insurance schedule showing the dates of cover and premium paid) Dac avei o poli anual, atunci va fi acceptat o copie a acesteia (if you have an annual policy then a fotocopy will be accepted) Ataat (enclosed)

Pentru daunele privind ntrzierea cltoriei: (in respect of travel delay claims) Confirmarea de ctre operator a motivelor exacte, ora i durata ntrzierii (confirmation from the operator of the exact reason, time, and length of delay) Pentru daunele privind pierderea mbarcrii: (in respect of missed departure claims) Confirmarea de ctre autoritatea ndreptait referitoare la motivele implicate [de exemplu: raport defeciuni, raport trafic, confirmare ntrziere companie aerian / nav] (confirmation from the appropriate authority confirming reason for missed departure; i.e.: breakdown report, traffic report, airline/ferry delay confirmation) Chitanele transportului alternativ i/sau cazrii pentru costurile suplimentare solicitate (receipts for the additional travel and/or accommodation costs being claimed) Dovada restituirilor efectuate de operator / compania aerian (evidence of refund from tour operator / airline) Dac ai cerut despgubiri i unei alte instituii, copia corespondenei (if you have submitted a claim to another authority, copies of all correspondence)

NOTIFICARE DAUN ANULAREA CLTORIEI / PIERDEREA AVANSULUI CANCELLATION / LOSS OF DEPOSIT CLAIM FORM
V mulumim pentru notificarea daunei. V rugm s completai acest formular i s-l transmitei ctre: Thank you for notifying us of you claim. Please complete this claim form and return it to: SPECIALTY CLAIMS SERVICES PO BOX 51541 LONDON SE1 0XU Dac avei nevoie de ajutor pentru completare, v rugm contactai-ne la: If you need any help in completing this form, please contact us on: +44 (0)20 7902 7410

Detaliile pgubitului Claimant details


Formul Adresare / Title Numele complet / Full Name Data naterii / Date of birth Ocupaie / Occupation ara de domiciliu / Usual Country of Domicile

Adresa pgubitului (claimant address):

Cod potal (postcode): Telefon (telephone): E-mail: (adresa de email poate fi utilizat pentru coresponden dac este menionat / e-mail may be used for correspondence if stated) Detaliile Asigurrii Insurance details Numr certificat (Certificate number): Compania de Asigurare (Insurance Company): Adresa brokerului (Address of Broker):

NOTIFICARE DAUN ANULAREA CLTORIEI / PIERDEREA AVANSULUI CANCELLATION / LOSS OF DEPOSIT CLAIM FORM

Detaliile cltoriei Travel Details Destinaie (travel destination): ara (country): Staiune (resort): Hotel (hotel): Data plecrii (departure date): Scopul Cltoriei (purpose of trip): Detaliile daunei Claim details Motivele anulrii: (reason for the cancellation) Dac motivele anulrii sunt unele medicale, certificatele medicale ataate vor trebui completate de ctre doctorul curant al persoanei a crei condiie a cauzat anularea cltoriei. (if the reason for cancellation is medically related, the attached medical certificates must be completed by the usual doctor of the person whose condition caused the cancellation of the trip) Dac anularea a fost determinat de o persoan care nu cltorea i care nu este asigurat prin polia dvs., v rugm menionai relaia dvs. cu acea persoan: (if the cancellation has been caused by a person not travelling and not insured on your policy, please state the relashionship of that person to you) Data la care ai achiziionat/rennoit polia: / (date your insurance policy was purchased or renewed) Perioada de acoperire menionat n poli: / (period of cover as stated on your travel insurance schedule) Data la care ai rezervat cltoria: (date you booked your trip) Total avans pltit: $ (total deposit paid) Total rmas pltit: $ (total balance paid) Total sum returnat: $ (total amount refunded) Suma Total Solicitat ca Daun: $ (total amount claimed) / / / / la (to) / / / / Data revenirii (return date): Recreere (Pleasure) / /

Afaceri (Business)

Data la care ai anulat cltoria: (date you cancelled your trip) Data pltii: (date paid) Data pltii: (date paid) Data returnrii: (date refunded) / / / / / /

NOTIFICARE DAUN ANULAREA CLTORIEI / PIERDEREA AVANSULUI CANCELLATION / LOSS OF DEPOSIT CLAIM FORM Ai solicitat i alte daune pentru anulri anterioare acestei daune? (have you made any cancellation claims prior to this claim?) Dac da, v rugm detaliai (if yes, please give details): DA (YES) NU (NO)

Deinei asigurare de cltorie asociat contului dvs. bancar? (do you hold any travel insurance with your current bank account?) Dac da, v rugm detaliai (if yes, please give details):

DA (YES)

NU (NO)

Deineti asigurare de cltorie asociat turoperatorului respectiv? (do you hold any travel insurance with the relevant tour operator?) Dac da, v rugm detaliai (if yes, please give details):

DA (YES)

NU (NO)

V-ai folosit cardul de credit pentru a achita total sau parial cltoria? DA (YES) (did you use your credit card to pay for all or part of your trip?) Dac da, v rugm s ne transmitei extrasul de cont aferent acestei tranzacii. (if yes, please provide the relevant card statement showing the transaction). Ai depus o cerere de despgubire la orice alt asigurtor / instituie? (have you submitted a claim to any other insurer / authority?) Dac da, v rugm detaliai (if yes, please give details): DA (YES)

NU (NO)

NU (NO)

Dac dauna dumneavoastr va fi acceptat, v rugm s menionai ctre cine va trebui pltit despgubirea: (if your claim is agreed, please state to whom settlement should be made): Numele Beneficiarului majuscule: (print payee name) Declaraie Declaration n deplin cunotin de cauz, declar c toate detaliile furnizate n acest formular sunt adevrate i corecte. n cazul n care o ter parte este rspunztoare pentru pierderile/pagubele produse, toate drepturile n aceast privin sunt subrogate Serviciului Daune pentru soluionarea daunei. Dac exist acoperire furnizat prin alt poli, mi dau acordul pentru stabilirea contribuiei de ctre asigurtori. Sunt contient c unele informaii furnizate de mine vor fi puse la dispoziia altor asigurtori pentru a fi folosite la subscriere sau la gestionarea daunelor. I declare that to the best of my knowledge all particulars contained in this form are true and correct. In the event of a third party being liable for loss/damage all rights in this matter are subrogated to Specialty Claims Service on settlement of the claim. If cover exists under any other policy, I give my authority for contribution to be sought from their insurers. I understand that some of the information provided will be made available to other insurers for underwriting or claims handling purposes. Semntura: (signed) Data: (date) / / Valuta preferat: (preferred currency)

NOTIFICARE DAUN ANULAREA CLTORIEI / PIERDEREA AVANSULUI CANCELLATION / LOSS OF DEPOSIT CLAIM FORM Instruciuni Guidance Notes Urmtoarele documente sunt necesare pentru a putea procesa cererea dvs. (the following documentation must be provided in order for your claim to be processed) Document (item) Factura original de rezervare care v-a fost trimis la momentul rezervrii cltoriei (your original booking invoice which is sent to you at the time of booking your trip) Dac ai fcut rezervri individuale (de exemplu: nchiriat maina, hotelul aeroportului) v rugm s ne furnizai facturile pentru fiecare dintre acestea (if you have booked independent arrangements i.e. car hire, airport hotel then please provide us with a booking invoice for each item being claimed) Factura original de anulare care v-a fost trimis la momentul anulrii cltoriei (your original cancellation invoice which is sent to you at the time of cancelling your trip) Dac ai fcut rezervri individuale (de exemplu: nchiriat maina, hotelul aeroportului) v rugm s ne furnizai facturile de anulare pentru fiecare dintre acestea (if you have booked independent arrangements i.e. car hire, airport hotel then please provide us with a cancellation invoice for each item being claimed) Polia de asigurare a cltoriei original, cu perioada acoperit i prima pltit (your original travel insurance schedule showing the dates of cover and premium paid) Dac avei o poli anual, atunci va fi acceptat o copie a acesteia (if you have an annual policy then a fotocopy will be accepted) Dovezile necisitii de a anula cltoria: (evidence of necessity to cancel your trip) - Medicale certficatul ataat (medical the attached medical certificate) - Ciclicitate informarea de ciclicitate confirmnd eligibilitatea pentru un astfel de pachet (redundancy redundancy notice confirming eligibility for redundancy package) - Solicitarea prezenei n instan Citaie (Court Attendance Court Subpoena) Dovada restituirilor efectuate de operator / compania aerian (evidence of refund from tour operator / airline) Dac ai rezervat curse de linie, toate taxele de aeroport trebuie solicitate companiei aeriene. (if you have booked scheduled flights, all air taxes must be claimed from the airline) Dac ai cerut despgubiri i unui alt asigurator, copia corespondenei (if you have submitted a claim to another insurer, copies of all correspondence) Ataat (enclosed)

NOTIFICARE DAUN CHELTUIELI MEDICALE NTRERUPEREA CLTORIEI MEDICAL EXPENSES / CURTAILMENT CLAIM FORM
V mulumim pentru notificarea daunei. V rugm s completai acest formular i s-l transmitei ctre: Thank you for notifying us of you claim. Please complete this claim form and return it to: SPECIALTY CLAIMS SERVICES PO BOX 51541 LONDON SE1 0XU Dac avei nevoie de ajutor pentru completare, v rugm contactai-ne la: If you need any help in completing this form, please contact us on: +44 (0)20 7902 7410

Detaliile pgubitului Claimant details


Formul Adresare / Title Numele complet / Full Name Data naterii / Date of birth Ocupaie / Occupation ara de domiciliu / Usual Country of Domicile

Adresa pgubitului (claimant address):

Cod potal (postcode): Telefon (telephone): E-mail: (adresa de email poate fi utilizat pentru coresponden dac este menionat / e-mail may be used for correspondence if stated) Detaliile Asigurrii Insurance details Numr certificat (Certificate number): Compania de Asigurare (Insurance Company): Adresa brokerului (Address of Broker):

NOTIFICARE DAUN CHELTUIELI MEDICALE NTRERUPEREA CLTORIEI MEDICAL EXPENSES / CURTAILMENT CLAIM FORM

Detaliile cltoriei Travel Details Destinaie (travel destination): ara (country): Staiune (resort): Hotel (hotel): Data plecrii (departure date): Scopul Cltoriei (purpose of trip): Detaliile daunei Claim details Data, ora i locul producerii bolii/vtmrii: (date, time and place of illness/injury) / / : AM PM / / Data revenirii (return date): Recreere (Pleasure) / /

Afaceri (Business)

Boala sau rnirile suferite (illness suffered or injuries sustained):

Pentru vtmri, v rugm detaliai circumstanele incidentului (if injury, please provide full circumstances of the incident):

Ai suferit de o boal asemntoare n trecut? . DA (YES) (have you suffered from a similar condition before?) Dac da, rugai doctorul curant s completeze certificatul medical ataat. (if yes, please ask your normal doctor to complete the medical certificate attached) Ai prezentat EHIC (card European de asigurri de sntate)? (numai pentru rile membre UE) (did you present your EHIC? EU countries only) Dac da, v rugm completai exonerarea de rspundere ataat. (if yes, please complete the disclaimer attached) Ai contactat serviciile medicale de urgen? (did you contact the Emrgency Medical Assistance Company?) Dac da, indicai numrul de referin furnizat: (if yes, please provide the reference number given to you)

NU (NO)

DA (YES)

NU (NO)

DA (YES)

NU (NO)

NOTIFICARE DAUN CHELTUIELI MEDICALE NTRERUPEREA CLTORIEI MEDICAL EXPENSES / CURTAILMENT CLAIM FORM Ai fost internat? Dac da, indicai: (were you hospitalized as an in-patient? If so, please provide): Data internrii (date admitted): / / Data externrii (date discharged): Ora Internrii (time admitted): : AM PM Ora Externrii (time discharged): Dac este cazul, perioada cazrii extinse: / (if applicable, period of extended accommodation) / pn : (to) / /

/ :

/ AM PM

V-ai ntors acas mai devreme? (did you return home early?) Dac da, specificai data revenirii: (if yes, please provide the date on which you returned)

DA (YES) /

NU (NO) /

Deinei orice alt asigurare care acoper acest tip de daun? DA (YES) NU (NO) (Do you hold any other insurance that may cover this loss?) Exemplu: Asigurri de Sntate, asigurri asociate contului bancar, operatorului de turism, cardului de credit (I.E: Private Health, Bank Account, Credit Card, Tour Operator) Dac da, furnizai detalii: (if yes, please give details)

Dac dauna dumneavoastr va fi acceptat, v rugm s menionai ctre cine va trebui pltit despgubirea: (if your claim is agreed, please state to whom settlement should be made): Numele Beneficiarului majuscule: (print payee name) Valuta preferat: (preferred currency)

Declaraie Declaration n deplin cunotin de cauz, declar c toate detaliile furnizate n acest formular sunt adevrate i corecte. n cazul n care o ter parte este rspunztoare pentru pierderile/pagubele produse, toate drepturile n aceast privin sunt subrogate Serviciului Daune pentru soluionarea daunei. Dac exist acoperire furnizat prin alt poli, mi dau acordul pentru stabilirea contribuiei de ctre asigurtori. Sunt contient c unele informaii furnizate de mine vor fi puse la dispoziia altor asigurtori pentru a fi folosite la subscriere sau la gestionarea daunelor. I declare that to the best of my knowledge all particulars contained in this form are true and correct. In the event of a third party being liable for loss/damage all rights in this matter are subrogated to Specialty Claims Service on settlement of the claim. If cover exists under any other policy, I give my authority for contribution to be sought from their insurers. I understand that some of the information provided will be made available to other insurers for underwriting or claims handling purposes. Semntura: (signed) Data: (date) / /

NOTIFICARE DAUN CHELTUIELI MEDICALE NTRERUPEREA CLTORIEI MEDICAL EXPENSES / CURTAILMENT CLAIM FORM

Detaliile cheltuielilor solicitate Details of expenses being claimed


Data cheltuielii (date of expense) Detalii (details of expense) Suma solicitat (claimed amount) Chitan Ataat? (receipt attached?) Pltit / nepltit? (paid / unpaid?) PENTRU UZUL BIROULUI (OFFICE USE ONLY)

Instruciuni Guidance Notes Urmtoarele documente sunt necesare pentru a putea procesa cererea dvs. (the following documentation must be provided in order for your claim to be processed) Document (item) Factura original de rezervare care v-a fost trimis la momentul rezervrii cltoriei (your original booking invoice which is sent to you at the time of booking your trip) Polia de asigurare a cltoriei original, cu perioada acoperit i prima pltit (your original travel insurance schedule showing the dates of cover and premium paid) Dac avei o poli anual, atunci va fi acceptat o copie a acesteia (if you have an annual policy then a fotocopy will be accepted) Dovezile ce susin dauna dvs: (evidence to support your claim) - Chitane originale / facturi pentru cheltuielile solicitate (original receipts/invoices for expenses being claimed) - Rapoartele/nregistrrile doctorului/spitalului (hospital/doctor reports/records) Dac v-ai ntors mai devreme acas: (if you returned home early) Confirmarea doctorului curant referitoare la necesitatea ntoarcerii anticipate acas, sau dac ntoarcerea a fost rezultatul unei boli/mori a unei rude, solicitm completarea certificatului ataat de ctre doctorul curant al persoanei care a cauzat ntreruperea cltoriei (confirmation from the treating doctor of the medical necessity to return early, or if the return was a result of an illness/death of a relative we require the medical certificate attached to be completed by the usual doctor of the person causing curtailment) Ataat (enclosed)

NOTIFICARE DAUN CHELTUIELI MEDICALE NTRERUPEREA CLTORIEI MEDICAL EXPENSES / CURTAILMENT CLAIM FORM Pentru cheltuieli medicale efectuate numai pe teritoriul UE, v rugm completai exonerarea de rspundere ataat . (for medical expenses incurred in the EU only, please complete the attached disclaimer) Dac cheltuielile au fost rezultatul unui incident: (if the expenses are a result of an incident) Copiile oricrui raport ntocmit de poliie (copies of any Police reports) Detaliile companiei de asigurare a terei persoane (details of the third partys insurance company) Detaliile oricrui avocat numit de dvs. pentru a instrumenta un caz de Vtmare Corporal (details of any solicitor that you may have appointed to handle a Personal Injury Claim) Dac ai cerut despgubiri i unui alt asigurator, copia corespondenei (if you have submitted a claim to another insurer, copies of all correspondence)

NOTIFICARE DAUN CHELTUIELI MEDICALE NTRERUPEREA CLTORIEI MEDICAL EXPENSES / CURTAILMENT CLAIM FORM Exonerare de rspundere (numai pentru rile UE) Disclaimer (EU countries only) Prin prezenta, sunt de acord ca SPECIALTY CLAIMS SERVICE s solicite rambursarea cheltuielilor medicale efectuate ca urmare a tratamentului medical; (I hereby consent to Speciality Claims Services seeking reimbursement of medical expenses paid arising out of medical treatement). Primit n (destinaie): (received in destination) Numele (majuscule): (print name) Adresa complet: (full address) de la (data mbolnvirii): (from date of illness) / /

Cod potal: (postcode) Data naterii: (date of birth) CNP: (NI number) Semnatura (signed) Data (date) / / / / Naionalitate: (nationality)

Dac cheltuielile medicale se refer la copilul dvs, menionai: (if medical expenses relate to your child, please confirm) Numele complet al copilului: (full name of child) Data naterii: (date of birth) / / Naionalitatea: (nationality) / /

Data plecrii n strintate: (date of departure abroad):

CERTIFICAT MEDICAL MEDICAL CERTIFICATE

A se completa de ctre Medicul de Famile al persoanei ce determin anularea cltoriei (indiferent dac participa sau nu la cltorie). Orice tarif solicitat pentru completarea acestui document este responsabilitatea Persoanei Asigurate i nu va fi restituit de ctre Asiguratori. (to be completed by the general practitioner of the person causing cancellation (whether travelling or not). Any charge made for the completion of this document is the responsibility of the insured person and is not refundable by the insurers). NOTA: pentru a evita ntrzierile i corespondena inutil, v rugm s completai acest formular cu MAJUSCULE i s rspundei ct mai cuprinztor la toate ntrebrile (to avoid delay and unnecessary correspondence please complete this form in BLOCK CAPITALS and answer each question as fully as possible)

1.

Numele complet al persoanei ale crei date medicale sunt completate (full name of the person to whom these medical details apply) 2. Data naterii i Vrsta (date of birth and Age) 3. Suntei medicul de familie al doamnei/domnului? Dac nu, n ce calitate suntei implicat? (are you his/her usual general practitioner? If not, in what capacity are you involved?) 4. V rugm menionai natura exact a bolii/accidentului care a determinat anularea (please state the exact nature of illness/accident which made cancellation necessary) 5. Exist un istoric medical precedent al bolii de mai sus sau alte boli relevante? Dac DA, furnizai detalii (is there any previous medical history of the above condition or other relevant condition? If YES, please give details) 6. Referitor la aceast boala, cnd a fost consultat prima oar pacientul? (when did the pacient first consult you with regard to this condition?) 7. Cnd a fost diagnosticat boala? (when was the condition diagnosed?) 8. Cnd a devenit necesar anularea cltoriei? (when was cancellation deemed necessary?) 9. Cunoteai planurile de cltorie cnd ai fost consultat prima oar? Dac NU, v rugm confirmai prima dat la care anularea cltoriei ar fi putut fi anticipat. (were you aware of the travel plans when first consulted? If NO, please confirm the first date pon which cancellation could have been anticipated) 10. Menionai dac la momentul rezervrii cltoriei (at the time the trip was booked, please state whether): a) Boala era sub control (The condition was under control) b) Aceasta este o agravare a unei boli existente, i dac da data agravrii (This was an exacerbation of any existing condition and if so the date of exacerbation) c) Pacientul era pe lista de ateptare pentru internare sau era dj internat (The patient was either on a waiting list for inpatient treatment or was an in-patient) d) Pacientul primise un diagnostic terminal (The patient had received a terminal prognosis) e) Dac pacientul cltorea, boala era o contraindicaie pentru cltorie (If the patient was one of those travelling, the condition was a contraindication to do so) f) Cltoria a fost efectuat n pofida sfaturilor medicale? (Was travelling contrary to medical advice?)

Data: / DA (YES)

/ NU (NO)

Varsta (age):

DA (YES)

NU (NO)

Data:

Data: Data: DA (YES)

/ /

/ / NU (NO)

Data:

DA (YES) DA (YES)

NU (NO) NU (NO)

Data:

DA (YES)

NU (NO)

Data:

DA (YES) DA (YES)

NU (NO) NU (NO)

Data:

DA (YES)

NU (NO)

CERTIFICAT MEDICAL MEDICAL CERTIFICATE


11. Doar n caz de sarcin (pregnancy only) a) Data ultimei menstruaii (date of LMP) b) Data confirmrii sarcinii (date pregnancy confirmed) c) Data estimat a naterii (estimated date of confinement) d) Condiiile medicale exacte ce mpiedicau calatoria (exact medical condition preventing travel) Data: Data: Data: / / / / / /

Certific c anularea cltoriei s-a datorat numai condiiilor medicale menionate. (I certify that cancellation was due solely to the medical conditions stated) Numele i semnatura: (name and signature) Calificri: (qualifications) Telefon: (telephone number)

tampila (practice stamp)