Loss Report Luggage Insurance



Chubb European Group LimitedDirektion für DeutschlandLurgiallee 1260439 Frankfurt am MainT +49 69 75613 0F +49 69 746193claims.service@chubb.deLoss ReportBusiness Travel InsurancePlease kindly answer all questions exactly and inform us immediately of everything you know about the incident.Even any information apparently negligible is of importance. In case you have any questions regarding the loss report, please do not hesitate to contact Chubb European Group Limited in Germany.Please note that false or incomplete data may lead to a loss of the insurance protection even if this will not result in a disadvantage of the insurer. I know that the insurer will check the data to be able to judge his obligation to provide indemnification, which I have given to substantiate the claims or which result from the documents I have submitted (e.g. certificates, attestations) or information initiated by me from a hospital or from members of a healthcare profession. For this purpose I exempt herewith the members of healthcare professions or hospitals being mentioned in the documents submitted or having taken part in the therapy from their professional discretion. In case of my death I also exempt them from their professional discretion to check with regard to entitlements to the insurer’s performance.This exemption from the professional discretion is also valid for authorities – apart from social insurance institutions, furthermore for the members of other accident, health or life insurers, who may be questioned with regard to existing insurance.Claims NumberClaims Number (will be completed by the insurer) FORMTEXT ?????Policy NumberDEBMNA17190Name of company FORMTEXT ?????Details of injured personFirst name and family name FORMTEXT ?????Street and street number FORMTEXT ?????Postal code/zip code: Town or City FORMTEXT ?????Date of birth FORMTEXT ?????Phone number with area code (during the day) FORMTEXT ?????Email FORMTEXT ?????Indemnifications for private property / health and accident claims to be paid to the following account of the insured personIBAN Number FORMTEXT ?????BIC FORMTEXT ?????Name and address of the financial institution FORMTEXT ?????Account holder / payee FORMTEXT ?????Indemnifications for BI property to be paid to the following account of Boehringer IngelheimIBAN Number FORMTEXT ?????BIC FORMTEXT ?????Name and address of the financial institution FORMTEXT ?????Account holder / payee FORMTEXT ?????Loss Report Luggage Insurance Details of the Travel arrangement bookedaTravel destination FORMTEXT ?????bType of travel (air/train/other) FORMTEXT ?????cStart of travel FORMTEXT ?????dEnd of travel FORMTEXT ?????Details of the Insurance casePlease enclose following documents as copy (PDF)Police record (only for robbery and burglary/theft)If applicable: confirmation of the damage reported to the carrier or the right to refuse payment or proof of payments made by the carrier.Please provide a list separate with private ownership and corporate ownership including evidence on the replacement value (e.g. expressions from the Internet) or the recovery calculation aWhen did the damage/loss happen? Date / time FORMTEXT ?????bWhere did the damage/loss happen? Street/garage/hotel/transport FORMTEXT ?????cWhere were the damaged objects when the damage/loss happened? Location FORMTEXT ?????dIf applicable: When was the vehicle parked? Date / Time FORMTEXT ?????eIf applicable: What type of vehicle? FORMTEXT ?????fWho ascertained the damage/loss? First and family name FORMTEXT ?????gDescription of the loss history/if necessary, please use supplementary sheet FORMTEXT ?????hWitnesses/evidences? First and family name/address FORMTEXT ?????iWhat did you do to diminish the damage/loss? FORMTEXT ?????jOther insurance protection? Name and address of the insurance company/policy numberIf so did you report the claim? FORMTEXT ????? FORMTEXT ?????Information about the loss/damage of luggage ObjectBought FromDatePriceDamage/Repair sum (estimate)Please note that false or incomplete data may lead to a loss of the insurance protection even if this will not result in a disadvantage of the insurer.I hereby certify that the insured person was on business trip an approved by BI on the occurrence of loss during the above period.Place and DateSignature of the insured personSignature of the ExecutiveLoss Report Delay of Luggage and FlightDetails of the travel arrangement booked aTour operator FORMTEXT ?????bTravel destination FORMTEXT ?????cbooked on FORMTEXT ?????dAirline FORMTEXT ?????eAirport Departure FORMTEXT ?????fAirport Arrival FORMTEXT ?????gDate of outbound flight/Flight number FORMTEXT ?????hDate of return flight/Flight number FORMTEXT ?????Details of the insurance casePlease enclose the following documents as copy (PDF):Airline ticketBoarding card / passenger’s couponEvidence of compensation already made by third party (e.g Airline)receipts of all articles bought (incl. replacements)aWhen were you informed about the delay of the flight/of the luggage? Date/ Time FORMTEXT ?????bWho informed you? Airline/tour management/territorial directive FORMTEXT ?????cReason for the delay? Strike/blockade/technical defect FORMTEXT ?????dWhen was the flight continued / when did the luggage transport take place? Date / time FORMTEXT ?????eWhen did you buy the convenience articles urgently needed? Date FORMTEXT ?????fWere indemnifications already made and by whom? FORMTEXT ?????Please note that false or incomplete data may lead to a loss of the insurance protection even if this will not result in a disadvantage of the insurer.I hereby certify that the insured person was on business trip an approved by BI on the occurrence of loss during the above period.Place and DateSignature of the insured personSignature of the ExecutiveLoss Report Accident and Health InsuranceDescription of the accident insuranceAttention: If you had an accident you have to complete additionally the accident claim form!aDate of accident FORMTEXT ?????bDescription of how the accident happened (please take a separat paper if needed) FORMTEXT ?????cWas the insured under the influence of alcohol or drugs? FORMCHECKBOX No FORMCHECKBOX YesdWas a blood sample taken? Result? FORMCHECKBOX No FORMCHECKBOX YeseWas the accident recorded by the police? FORMCHECKBOX No FORMCHECKBOX YesfName / address of the witness(es): FORMTEXT ?????gKind of injury FORMTEXT ?????hDate, name and address of the attending medical doctor(s) / hospital FORMTEXT ?????iWere you ever before treated due to this injury? If yes, by whom? FORMTEXT ?????Description of the illness insuranceaWhen did the symptoms occur for the first time? FORMTEXT ?????bKind of ilness FORMTEXT ?????cDate, name and address of the attending medical doctor(s) / hospital FORMTEXT ?????dWere you ever before treated due to this ilness? If yes, by whom? FORMTEXT ?????I hereby certify that the insured person was on business trip an approved by BI on the occurrence of loss during the above period.Place and DateSignature of the insured personSignature of the Executive ................
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