How To Fill Out An Accident Claim Form In Luxembourg

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Policy number L2.040.140

AIG Europe Limited. Registered in England. Company number: 01486260.

Registered Office: The AIG Building, 58 Fenchurch Street, London EC3M 4AB, United Kingdom. Belgian branch office located at Pleinlaan 11, 1050 Brussels, Belgium.

Tel: (+32) (0) 2739 9000

RPM/RPR Brussels - VAT n° 0847.622.919

Bank account number: 570-1210370-62 - IBAN: BE51 5701 2103 7062 - BIC: CITIBEBX with Citibank Bank You can find our Privacy Policy on www.aig.be/be-privacy-policy

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Insurer: AIG Europe Limited – Belgian branch

Claims Administrator: AIG Europe Limited, Belgian branch

Claims Department

Boulevard de la Plaine, 11 1050 Brussels - Belgium

: +32 2 739 91 04

: claims.be@aig.com

Issuer of the Card: Banque de Luxembourg

14, boulevard Royal L-2449 Luxembourg Luxembourg

Cardholder (name and address):

__________________________________________________________________________________ __________________________________________________________________________________

Card number: ffff-ffXX-XXXX-ffff

Type of the Card:

Banque de Luxembourg Visa Classic Banque de Luxembourg MasterCard Blue

Banque de Luxembourg Visa F Banque de Luxembourg MasterCard Gold

Banque de Luxembourg Visa Premier Banque de Luxembourg MasterCard Silver

Banque de Luxembourg Visa Infinite Banque de Luxembourg Visa Web Banque de Luxembourg Visa Business Insured and Trip details:

• Surname and Last Name : ________________________________________________________

• Address : _____________________________________________________________________

_____________________________________________________________________________

• Date of Birth : ffffffff / ffffff / fff fffffffffffffff

• Telephone home / office : ________________________________________________________

• E-mail : _______________________________________________________________________

• Country of domicile : ____________________________________________________________

• Departure Date : ffffffff / ffffff / fff fffffffffffffff from _________________ to : ____________________

• Return Date : ffffffff / ffffff / fff fffffffffffffff from __________________ to : ______________________ GENERAL INFORMATION

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• Nature of the trip : Private Business

• Number of travellers: ___________________________________

• Identity of the victim(s) if not the cardholder : ___________________________________________

• _______________________________________________________________________________

• Relationship to the cardholder : _____________________________________________________

Reimbursement (cf. Terms and Conditions of the Insurance), please mention your banking details from your Bank account at Banque de Luxembourg.

Banque de Luxembourg SWIFT (BIC) : BLUXLULL

IBAN : LUff-ffff-ffff-ffff-ffff

(International Banking Account Number)

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Tel: (+32) (0) 2739 9000

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• Date of payment with the Card: ffffffff / ffffff / fff fffffffffffffff

• Date of the loss / injury : fffffff / ff fffff / fff fffffffffffffff

• Circumstances and location of the loss / injury :

_____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ • Description : _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

• Subrogation possibilities and actions already taken :

_____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

• Is there any right of action / recovery against a third party?

_____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

• Have you taken any action in this respect yourself?

_____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

CLAIM

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Personal Data

Your personal data (hereinafter the "Data"), reported to the Insurer, will be processed in accordance with the Act of 8 December 1992 on the protection of privacy. The Data will be processed for the purpose of management and optimal use of the services provided by the Insurer, including risk assessment, contract management, claims handling and crime prevention (such as fraud) as well as to allow the Insurer to fulfil its legal obligations. To achieve these objectives and for the purpose of good service, the Insurer may be required to transfer Data to other companies of the AIG group, to sub-contractors or to partners. These companies, subsub-contractors or partners may be located in countries outside the European Economic Area that do not necessarily offer the same level of protection as Belgium but in this case, the Insurer has taken and shall take all precautionary measures to ensure an adequate level of protection and provide legal certainty to the Policyholder.

To the extent that the Insurer deals with sensitive data, they are only accessible, as far as necessary, to amongst others claims managers, risk analysts, underwriters and the legal department. You will find a complete list and, more generally, the complete Privacy policy of the Insurer on www.aig.be/be-privacy-policy.

According to the law, the data subject is entitled to access, amend or oppose (for a reasonable cause) to the processing of Data relating to him. To exercise these rights, he/she can contact the Insurer (AIG Europe Limited, Belgian branch) at any time in writing at Boulevard de la Plaine 11, 1050 Brussels. In as far as necessary and in particular in respect of any sensitive data (like its health-status), the data subject herewith approves the processing and the transfer of the Data as described here above. By signing this form, you moreover give your approval for the medical advisor appointed by the Insurer to get medical information (including regarding cause of death) from the treating doctor(s), and also allow for a medical examination, if needed.

Declaration of the Insured

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.

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Tel: (+32) (0) 2739 9000

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Under what circumstances did the accident take place?

f ff

f You were passenger on public transport f

ff

f You were hit by a public transport vehicle f

ff

f During boarding or alighting f

ff

f You were at the boarding point f

ff

f You were en route to or from the boarding point f ff f Other: _______________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Transport Company: _________________________________________________________________ Place, date and time of the accident: ____________________________________________________ Name and address of the witnesses (Please mention on the verso or separately)

Documents to be enclosed with this present notification:

• Copy of your Card statement (if not yet received, please send in when available),

• Medical report,

• Name and address of the hospital,

• Copy of the invoice of the travel ,

• In case of loss of life :

• Certificate of death signed by the competent local authority;

• Evidence of legal beneficiaries signed by the competent local authority;

• All invoices and documents relating to the repatriation;

• Name and address of the insured’s executor or legal representative. Declaration of the Insured

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

Your claim will be assessed following the receipt of a duly filled in Claims Notification Form, proof of payment, and all required substantiating documents. Please send this claim form together with all required substantiating documents as soon as possible to the Claims Administrator by mail, by email or by fax.