Claims notification Travel indemnity insurance

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Claims notification Travel indemnity insurance

Page 1 from 4 Claims processing by

Care Concept AG

PO Box 30 02 62, 53182 Bonn, Germany

FBVNHV150522 Tel.: + 49 228 97735-22 Fax: +49 228 97735-922 e-Mail: leistung@care-concept.de Internet: www.care-concept.de

To process the claim on behalf of the relevant insurer we need some further information. We therefore ask you to complete this form, sign it and send it back to us as soon as possible. Thank you

Certificate of insurance number: (please quote in all correspondence)

1. Policyholder:

Title: □ Mr □ Ms □ Company Surname:

First name:

Address: Street: Post code: Town/city: e-Mail address:

Tel.:

Tel. (mobile/cell): Fax:

2. Person who caused the loss:

Title: □ Mr □ Ms

Surname: First name: Date of birth:

Address: Street: Post code: Town/city: Travel into / out of

the country:

(please enclose appropriate evidence (copy of visa, etc.))

on: _{Return scheduled for:}

E-mail address: Tel.:

Tel. (mobil): Fax: Occupation/ most recent job:

3. Person suffering the loss:

Address: Street: Post code: Town/city: Driving license: Date of issue: Issuing agency:

The person suffering the loss and the policyholder or person insured are connected by a

□ Family relationship, namely:

□ living arrangement under the same roof

□ employment / work / other contractual relationship,

namely:

Injury: □ yes □ no

4. Additional party / witness (please note any further parties/witnesses on a separate sheet):

Address: Street: Post code: Town/city:

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Care Concept AG

5. Details of the accident Date of loss/injury: Time:

Where the

damage/loss occured: Details recorded by the police:

□ yes □ no

Office/station:

Address: File reference:

6. Outline description/sketch: (please also enclose any photos)

7. Further details where one or more vehicles were involved:

Vehicle A Vehicle B

Type (e.g. car, truck, motorcycle) Manufacturer Model Registration Number year Damage Prior damage Insured with Leased vehicle

□ yes □ no The vehicle is a business asset □ yes □ no □ Vehicle was parked □

□ Was moving off □

□ Stopped □

□ Was leaving a car park, property, etc. □ □ Was turning into a car park property, etc. □

□ Was braking □

□ Was approaching from behind □

□ Was travelling parallel in another lane □

□ Changed lanes □

□ Turned off to the right □

□ Turned off to the left □

□ Was overtaking □

□ Was travelling in the opposite direction □

□ Was reversing □

□ Did not give way (e.g. at traffic lights) □

□ Speed prior to collision □

□ yes □ no Driver under the influence of alcohol □ yes □ no □ yes □ no Left the scene of the accident □ yes □ no 8. Supplementary details

Claims have already been made:

(Please enclose correspondence)

□ Yes, in the amount of EUR □ no

I consider the claims justified: □ Yes, because □ no, because Any compensation is to be

paid: □ Policyholder / account

BIC: IBAN:

Claimant / account BIC:

IBAN: Entitlement to reclaim input

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Care Concept AG

9. Information in cases of damage to property What was damaged?

Nature and extent of

damage: Type (e.g. scratch, scorch mark): Extent (e.g. scratches everywhere, small mark/stain) The item was bought: on approximately: _{Price (approx.): EUR}

(enclose proof of purchase, if available) Value of damage: approximately.: Repair possible: □ yes □ no

(if yes, please enclose estimate) Inspection: An inspection was carried out by

Name: Address: Tel.:

The item is available for inspection at the premises of

Name: Address: Tel.: The item was in the

possession of you / your family / business employees under the following arrangement:

Rental/hire: □ yes □ no Loan…: □ yes □ no

Lease: □ yes □ no Safekeeping: □ yes □ no

Was the damage incurred by the item as a result of an activity

□ yes (e.g. repair, etc.), namely □ no The object is covered

under another valid policy:

□ Glass □ Fire □ Mains water □ Home contents □ TPFT- □ Fully comprehensive

□ Other (e.g. mobile/cell phone policy) Policy number:

with: Name: Address:

10. Details of personal injuries Name, address, date of birth of the injured person:

Street:

Post code: Town/city: Tel.:

Nature and extent of

injury: Nature (e.g. bruising) Extent (e.g. all over the body) The injured person is

employed by (employer): Surname: First name:

Company (where applicable):

Street:

Post code: Town/city: Tel.:

Inpatient treatment: □ yes, from: to □ unknown Attending physician: Initial treatment was undertaken by:

Name: Address: Tel.:

Subsequent treatment was undertaken: Name:

Address: Tel.: Reported to a □ yes, to name:

Address: File reference:

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Care Concept AG

Important notes on the consequences of breaches of obligations following the claims event: Cautionary guidance pursuant to Sect. 28 IV of the German Insurance Policies Act (VVG) Dear Customer,

once the claims event has occurred, we need your help

Duty to provide information and clarification

On the basis of the matters of contractual agreement reached with you, the Insurer, represented by Care Concept AG, may require you to provide any and every item of information that is necessary in order to verify the claims event or the extent of its obligation to provide indemnity (duty to provide information) and, by means of providing all detail helpful towards clarifying the facts of the matter (duty to provide

clarification), to enable it to examine its obligation to provide indemnity . The Insurer may also require you to provide it with evidence / documents where this may be reasonably demanded of you.

No obligation to provide indemnity

Where, contrary to the matters of contractual agreement, you wilfully provide false account or no account whatsoever or where you wilfully fail to provide the Insurer, represented by Care Concept AG, with the required evidence / documents, you will not forfeit your entire claim, but the Insurer may curtail its indemnity in keeping with the gravity of such failing on your part. No curtailment shall occur where you provide evidence to the effect that you have not violated the obligation through gross negligence. Despite breach of your obligations to provide information or clarification or to procure evidence / documents, the Insurer shall nonetheless remain obliged to provide indemnity to the extent that you provide evidence to the effect that the wilful or grossly negligent breach of obligation was not causal either to ascertainment of the claims event or to the extent of the obligation to provide indemnity.

Where you are in fraudulent breach of your obligations to provide information or clarification or to procure evidence / documents, the Insurer shall in all cases be free of any obligation to provide indemnity.

End of cautionary guidance

N.B.: Where the right to contractual indemnity is the entitlement not of you, but of a third party, such third party shall likewise be obliged to provide information and clarification and to procure documentary evidence. Final declarations

I confirm that my above statements are truthful and complete. I am aware that incorrect and / or incomplete information may result in loss of insurance cover. I have taken note of the above statements pursuant to Sect. 28 Para. 4 of VVG regarding the consequences of breaches of obligations following occurrence of the claims event.

I am aware that I am also responsible for the accuracy and completeness of details provided by me even where I have not completed this form personally.

I assign to the Insurer providing insurance cover my claims and entitlements, to the value of the indemnity provided by such Insurer, against any party causing the accident / liable party / other party under an obligation to provide indemnity.

I hereby give my consent that the insurer providing the cover and the administrator Care Concept AG may collect, store, use and transfer between them personal data pertaining to me to such extent as may be required for purposes of checking the application and of establishing, executing or terminating the insurance policies and of invoicing commission payments.

(Place, Date (Signature of policyholder) and (Signature insured person or his/her legal representative)

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Questionnaire for claimants

Page 1 of 8 Claims processing by

Care Concept AG

FBASHV150522 Tel.: + 49 228 97735-22 Fax: +49 228 97735-922 E-Mail: leistung@care-concept.de Internet: www.care-concept.de

To process the claim on behalf of the relevant insurer we need some further information.

We therefore ask you to complete this form, sign it and send it back to us as soon as possible. Thank you!

Certificate of insurance number: please quote in all correspondence)

1. Claimant:

Title: □ Mr □ Ms □ Company Surname:

First name:

Address: Street: Post code: Town/city: Date of birth: Qualified occupation: Most recent job/position: e-Mail address: Tel.: Fax: Tel. (mobile/cell):

Bank details: Account holder: Surname: BIC/sort code

Firstname:

IBAN / account no..: 2. Person who caused the loss (policyholder / insured person):

Address: Street: Post code: Town/city: e-mail address:

Tel.: Fax:

Tel. (mobile/cell):

Insured person: Surname: First name:

Street: House number:

Post code: Town/city:

3. Other party to the accident / witness (please note any further parties/witnesses on a separate sheet):

Surname: First name:

Address: Street: Post code: Town/city: e-Mail address:

Tel.: Fax:

Tel. (mobile/cell): 4. Details of the accident

Date of damage/

loss: Uhrzeit:

Where the damage/ loss occurred:

Recorded by: Office/station: File reference:

Street: Post code / Town/city:

5. Outline description / sketch (please also enclose any photos)

________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________

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Care Concept AG

6. Further details where one or more vehicles were involved

Vehicle A: Vehicle B:

Type (e.g. car, truck, motorcycle) Make & model

□ Vehicle was parked □

□ Was moving off □

□ Stopped □

□ Was leaving a car park, property, etc. □ □ Was turning into a car park property, etc. □

□ Was breaking □

□ Was approaching from behind □ □ Was travelling parallel in another lane □

□ Changed lanes □

□ Turned off to the right □

□ Turned off to the left □

□ Was overtaking □

□ Was travelling in the opposite direction □

□ Was reversing □

□ Did not give way (e.g. at traffic lights) □ □ Speed prior to collision □

□ yes □ no Driver under the influence of alcohol □ yes □ no □ yes □ no Left the scene of the accident □ yes □ no 7. Details in the case of damage to one or more objects:

What was damaged:

Who is the owner of this object:

Is the object a business asset: □ yes □ no Is it possible to reclaim input VAT

(value-added tax): □ yes □ no Nature and extent of damage:

When / at what price was the object acquired:

(if available please enclose proof of purchase)

Date (approx.): Price (approx.): € Estimated cost of

restoration/repair:

(please attach cost estimate)

approx. € Estimated duration of repair work:

approx. days The object is available for viewing at the

premises of: Name / Address:

Tel.:

The object has been viewed by: Name / Address: Tel.:

Previous damage: Number:

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Care Concept AG

The object is covered under a valid policy (tick type of policy):

□ glass □ fire □ mains water □ home contents

□ third party, fire and theft □ fully comprehensive

□ other,

e.g. mobile / cell phone policy; as follows:

Insurer: Address: Policy no.:

Claim/loss has already been reported to this insurer: □ yes □ no

Additional information in the case of car damage Type of vehicle:

Make & model: Year of manufacture: Mileage (km): Registration number: Number of previous owners:

The car is insured as follows: Third party cover: □ yes □ no Fully comprehensive: □ yes (policy excess _____________ €) □ no TP Fire & Theft: □ yes (policy excess _____________ €) □ no

Vehicle recovery service: Insured with:

Policy no.:

Where a total loss (write-off) situation does not apply, we recommend the repair work be put in hand immediately, bearing in mind your statutory duty to minimise the loss.

The liable party will not cover a loss arising due to any delay in issuing a repair instruction.

When issuing instructions, the repairer's attention should be drawn to the fact that the invoice is to be issued in accordance with the work value lists published by the manufacturers.

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Care Concept AG

8. Details where someone has been injured (where someone has sustained injury, please also complete and sign the statement of confidentiality waiver at the bottom of this form):

Injured person: Surname: First name: Address: Street: House number:

Post code: Town/city: Country: Current contact details: Tel.:

Mobile/cell E-Mail: Date of birth: Employer: Name: Address: Tel.: Qualified occupation:

Most recent job:

Self-employed: □ yes, as □ no Annual income: gross: € net € Marital status:

Dependents

(e.g. children): Number: Ages: Health insurance scheme:

□ state health insurance □ private health insurance □ private supplementary cover

Name: Address: Policy number: Name of relevant pension scheme

agency: Name:

Address: Policy number: Was this a workplace / commuting

accident: □ yes □ no Name of relevant Statutory Institute for Work Accident Insurance &

Prevention: Name: Address: File reference:

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Care Concept AG

9. Additional details where someone has been injured: Nature and extent of injuries sustained:

The injuries have healed completely □ yes □ no Inpatient treatment for injury: □ yes, from to □ no

Hospital providing treatment: Name:

Address:

Outpatient treatment for injury: □ yes, from to □ no Attending physicians:

Name: Address:

Other treatment at/by: Name:

Address:

Sick leave: □ yes, from to □ no The injury was sustained despite

protective features: □ yes □ no

The following protective feature was in use:

□ Safety belt □ Helmet (motorcycle, bicycle or crash helmet) □ special protective clothing (e.g. motorcycle clothes, work shoes)

Important notes:

I confirm that my above statements are truthful and complete. I am aware that I am also responsible for the accuracy and completeness of details provided by me even where I have not completed this form personally.

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Care Concept AG

Consent to the collection of medical information Statement of confidentiality waiver

Consent to the collection and use of medical information and statement of confidentiality waiver 1. Collection, storage, use and disclosure of personal data:

I hereby give my consent that the insurer providing the cover (hereinafter referred to as "Insurer") and the administrator Care Concept AG (hereinafter referred to as "Care Concept") may collect, store, use and transfer between them personal data pertaining to me to such extent as may be required for purposes of checking the application and of establishing, executing or terminating the insurance policies and of invoicing commission payments.

2. Collection, storage and use of medical data:

In order to be allowed to collect and use your medical data for this benefit application and in connection with the policy, the Insurer and Care Concept require your consent under data protection legislation and your confidentiality waivers in order to be able to collect your medical data from holders, such as doctors, who are under a duty of confidentiality, and in order - where necessary - to pass your medical data and other data falling under the protection of Sect. 203 of the German Penal Code to other recipients. The following statements of consent and confidentiality waiver are

indispensable for purposes of checking the application and for establishment, execution or termination of your insurance policy. If you choose not to make them, it will generally not be possible to set up the policy.

I hereby give my consent that the Insurer and Concept may collect, store, use and transfer between them medical data disclosed by me in this claim notification and at any time in the future to such extent as may be necessary for purposes of checking the application and of establishing, executing or terminating this insurance policy.

3. Disclosure of your medical data to entities not pertaining to the Insurer

The Insurer shall subject downstream entities to a contractual duty to observe data protection and data security regulations.

3.1 Disclosure of data for medical assessment purposes

Where medical assessors have to be brought in for purposes of assessing the risks to be insured and of examining the obligation to provide benefits, the Insurer and Care Concept require your consent and confidentiality waiver where this involves disclosure of your medical data and other data subject to protection under Sect. 203 of the German Penal Code. You will be informed of each instance in which data is passed on.

I hereby give my consent that the Insurer and Care Concept, in its administrative capacity, may pass on my medical data to medical assessors where necessary for risk assessment purposes or for purposes of examining the obligation to provide benefits and where my medical data are used by such recipient(s) in accordance with the intended purpose and where the outcomes are passed back to the relevant Insurer. With regard to my medical data and other data protected under Sect. 203 of the German Penal Code, I hereby release persons working for Care Concept and the Insurer examining my potential

entitlements and the assessors from their duties of confidentiality.

3.2 Disclosure of data where functions as assigned to other entities

Certain tasks, such as claims processing, telephone customer service and the emergency hotline, which may involve collection, processing or use of your data, are not handled by the Insurer and Care Concept in-house, but are rather assigned to other entities. Where your data falling under the protection of Sect. 203 of the German Penal Code is passed on, Care Concept and the relevant Insurer require a confidentiality waiver from you for these entities.

I hereby give my consent that the Insurer and CareConcept may pass my medical data to • D+S communications center management GmbH, Hamburg

• H.B.C. Hanse Betreuungscenter GmbH, Hamburg • Roland Assistance GmbH, Cologne

• Insurance Warehouse Gesellschaft für Finanzdienstleistungen GmbH, Hamburg

and that the medical data will be collected, processed and used there for the stated purposes to the same extent as the Insurer and Care Concept would be permitted so to do. To the extent necessary, I hereby release the staff of the Insurer and of Care Concept and of other entities from their duties of confidentiality with respect to disclosure of medical data and other data subject to the protection of Sect. 203 of the German Penal Code.

The list does not purport to be exhaustive as changes may have occurred in the meantime. A current list may be obtained by written request to Care Concept.

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Care Concept AG

3.3. Disclosure of data to reinsurers

In order to safeguard the meeting of your claims and entitlements, the Insurer and Care Concept avail themselves of reinsurance arrangements which assume the risk either in part or in whole. Information concerning your existing policies may be disclosed to reinsurers for purposes of settling commission payments and benefit payouts and for purposes of invoicing reinsurance arrangements and also in connection with risk and claims assessment. Your personal data will be used by the reinsurers for the aforementioned purposes only. You will be informed by the Insurer and by Care Concept regarding disclosure of your medical data to reinsurers.

I hereby give my consent to disclosure of my medical data - where necessary - to reinsurers and to their use thereof for the purposes mentioned. To the extent necessary, I hereby release the staff acting for the Insurer and for Care Concept from their duties of confidentiality with respect to the medical data and other data subject to the protection of Sect. 203 of the German Penal Code.

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Care Concept AG

Statement of confidentiality waiver

Name of the person

making the statement: First name:

D.O.B.: in:

Address: Post code,

town/city: Date of the accident the of

first symptoms of medical disorder:

in: Certificate of insurance

number:

I am aware that, for purposes of assessing its duty to pay insurance benefits, the relevant Insurer, represented by Care Concept AG, shall examine the information provided by me in support of my claims/entitlements or transpiring from documents submitted by me (e.g. certifications, attestations, etc.) or transpiring from communications which I have caused to be sent by a hospital or medical practitioner.

For this purpose, I release

Title Name Street, House no. Post code Town/city

from his/her duty of doctor-patient confidentiality

This confidentiality waiver also applies to authorities - with the exception of social security institutions - and also to staff of other accident, health and life insurers who may be asked to provide details of relevant existing insurance arrangements involving them.

I am issuing this statement on behalf of who is not in a position to judge the implications of this statement. (In cases of legal guardianship, please enclose a copy of the certificate of appointment / the guardian ID document)

__________________________ ___________________________________________________ (Place, Date) (signature of the claimant or his/her legal representative)