ING VISA CLASSIC / MASTERCARD STANDARD – CLAIMS NOTIFICIATION FORM « TRAVEL ACCIDENT INSURANCE » (page 1 of 5) Policy number BEBOAA01016
GENERAL INFORMATION •
Issuer of the ING Visa classic or Mastercard Standard card: ING Belgique S.A avenue Marnixlaan 24 B -1000 Brussels - Belgium
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Insurer : ACE European Group Limited Avenue des Nerviens/Nerviërslaan 9-31 B 1040 Brussels - Belgium Tél. 32 2 516 97 83 email :
[email protected]
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Cardholder ING Visa classic or Mastercard Standard card (name and address) :
___________________________________________________________________________________ ___________________________________________________________________________________
ING Visa classic or Mastercard Standard card number:
ffff-ffff - ffff-ffff •
Insured and trip
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Surname and Last Name : _________________________________________________________________
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Address : _______________________________________________________________________ ______________________________________________________________________
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Date of Birth : ff
/ ff / ffff
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Telephone home / office : ___________________________________________________
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E-mail : _________________________________________________________________
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Home country : _________________________________________________________
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Departure on : ff
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Return on : ff
/ ff / ffff from ___________________ tp : __________
/ ff / ffff from ___________________ to:__________
ACE European Group Limited, Avenue des Nerviens 9-31/Nerviërslaan 9-31, 1040 Brussels
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Company Number : 867.068.548 - Registered Office : 100 Leadenhall Street, London EC3A 3BP, UK. Company Number: 1112892. Company agreed to write following insurance classification of risks : 01a, 02, 03, 04, 05, 06, 07, 08, 09, 10a, 10b, 11, 12, 13, 14, 15, 16, 17, 18 - M.B. 13-09-2004 - Code NBB/BNB 2312
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ING VISA CLASSIC / MASTERCARD STANDARD – CLAIMS NOTIFICIATION FORM « TRAVEL ACCIDENT INSURANCE » (page 2 of 5) Policy number BEBOAA01016 •
Nature of the trip : Leisure Business
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Number of travellers:_____________________________________________________
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Name and address of the victim(s) if not the Cardholder: _________________________________________________________________________ _________________________________________________________________________
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Relationship with the ING Visa classic or Mastercard Standard card Cardholder: _________________________________________________________________________
REIMBURSEMENT (cf. Terms and Conditions of the Insurance) •
Bank account number IBAN: ffffffffffffffff BIC
•
ffffffff
Name and address of the bank :
_____________________________________
______________________________________________________________________
ACE European Group Limited, Avenue des Nerviens 9-31/Nerviërslaan 9-31, 1040 Brussels
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Company Number : 867.068.548 - Registered Office : 100 Leadenhall Street, London EC3A 3BP, UK. Company Number: 1112892. Company agreed to write following insurance classification of risks : 01a, 02, 03, 04, 05, 06, 07, 08, 09, 10a, 10b, 11, 12, 13, 14, 15, 16, 17, 18 - M.B. 13-09-2004 - Code NBB/BNB 2312
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ING VISA CLASSIC / MASTERCARD STANDARD – CLAIMS NOTIFICIATION FORM « TRAVEL ACCIDENT INSURANCE » (page 3 of 5) Policy number BEBOAA01016
CLAIM (to be completed by the ING Visa classic or Mastercard Standard card Cardholder or his legal representative •
Date of payment of the trip with the ING Visa classic or Mastercard Standard card ff / ff / ffff
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Date of the accident/death : ff / ff / ffff
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Circumstances and location of the accident/death : _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________
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Detailed description of the circumstances : _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________
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Is there any right of action / recovery against a third party ? _________________________________________________________________________ _________________________________________________________________________
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Have you taken any action in this respect yourself ? _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________
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What are the potential witnesses of the accident/death? - Surname and Last Name : __________________________________________________ - Address :________________________________________________________________ _________________________________________________________________________ - Tel:_____________________________Email:___________________________________
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Has a Police report be drawn up ? By which corps ? Name and address : __________________________________________________________________________
ACE European Group Limited, Avenue des Nerviens 9-31/Nerviërslaan 9-31, 1040 Brussels
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Company Number : 867.068.548 - Registered Office : 100 Leadenhall Street, London EC3A 3BP, UK. Company Number: 1112892. Company agreed to write following insurance classification of risks : 01a, 02, 03, 04, 05, 06, 07, 08, 09, 10a, 10b, 11, 12, 13, 14, 15, 16, 17, 18 - M.B. 13-09-2004 - Code NBB/BNB 2312
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ING VISA CLASSIC / MASTERCARD STANDARD – CLAIMS NOTIFICIATION FORM « TRAVEL ACCIDENT INSURANCE » (page 4 of 5) Policy number BEBOAA01016
CLAIM (to be completed by the ING Visa classic or Mastercard Standard card Cardholder or his legal representative •
What are the circumstances of the accident/death ? As passenger of a means of public transport /rental vehicle Were you hit by a means of public transport ? During the embarkation/getting off. You were on the place of the embarkation You were on the way to and from the place of the embarkation
Other circumstances : ........................................................................................................................................... ............................................................................................................................................ ………………………………………………………………………………………………………. Transport company: ......................................................................................................... In case of repatriation of the dead body/search and rescue costs Paid expenses Date
Provider
Amount
The undersigned certifies having correctly replied to all questions in all honesty, to the best of his/her knowledge, and certifies that no information with relevance to the claim has been withheld. Date + signature of the Insured _______________________ ____________________________________ The handling of your file is possible after receipt of a duly completed claim form with all required substantiating documents to be send as soon as possible to ACE European Group Limited, avenue des Nerviens/Nerviërslaan 9-31 à 1040 Brussels.
ACE European Group Limited, Avenue des Nerviens 9-31/Nerviërslaan 9-31, 1040 Brussels
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Company Number : 867.068.548 - Registered Office : 100 Leadenhall Street, London EC3A 3BP, UK. Company Number: 1112892. Company agreed to write following insurance classification of risks : 01a, 02, 03, 04, 05, 06, 07, 08, 09, 10a, 10b, 11, 12, 13, 14, 15, 16, 17, 18 - M.B. 13-09-2004 - Code NBB/BNB 2312
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ING VISA CLASSIC / MASTERCARD STANDARD – CLAIMS NOTIFICIATION FORM « TRAVEL ACCIDENT INSURANCE » (page 5 of 5) Policy number BEBOAA01016
PROOF OF LOSS DOCUMENTS Documents to be enclosed with this present notification In all case, the proof that the payment of the trip was made with the ING Visa classic or Mastercard Standard card (copy of the Card statement). • Doctor’s certificate • Name and address of the hospital • Copy of the trip invoice • Document proving the utilization of a means of transport/rental vehicle and/or claim filed with the transport company. • Police report In case of death : • Extract of the death certificate signed by the local authority • Original certificate of inheritance • Documents relating to the repatriation • Name and address of the legal heirs or legal representative
Declaration of the Insured The undersigned declares that the above information are complete, correct and exclusively related to the loss and that the fees have not been reported to another company to recover the costs from a third party liable. Date + signature of the Insured
____________________
_______________________________________________
ACE European Group Limited, Avenue des Nerviens 9-31/Nerviërslaan 9-31, 1040 Brussels
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Company Number : 867.068.548 - Registered Office : 100 Leadenhall Street, London EC3A 3BP, UK. Company Number: 1112892. Company agreed to write following insurance classification of risks : 01a, 02, 03, 04, 05, 06, 07, 08, 09, 10a, 10b, 11, 12, 13, 14, 15, 16, 17, 18 - M.B. 13-09-2004 - Code NBB/BNB 2312
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