1-2 Insurance claim – Travel cancellation /
1-2 Insurance claim – Travel cancellation /
1-2 Insurance claim – Travel cancellation /
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<strong>Insurance</strong> <strong>claim</strong> <strong>–</strong> <strong>Travel</strong> <strong>cancellation</strong> /<br />
LUXAIR Airline<br />
A A complete complete report report facilitates facilitates the the processing processing of of your your <strong>claim</strong> <strong>claim</strong>! <strong>claim</strong><br />
Purpose Purpose of of the the <strong>claim</strong> :<br />
� <strong>Travel</strong> <strong>Travel</strong> <strong>cancellation</strong><br />
AXA AXA Assurances Assurances Luxembourg<br />
Luxembourg<br />
Société anonyme - 7, rue de la Chapelle L <strong>–</strong> 1325 Luxembourg <strong>–</strong> R.C. Luxembourg : B 53466<br />
Kindly Kindly complete complete this this form form form and and return return it it it ASAP ASAP ASAP to<br />
to<br />
AXA AXA Assurances Assurances Luxembourg<br />
Luxembourg<br />
Luxembourg<br />
7, 7, rue rue de de de la la Chapelle Chapelle Chapelle LL-1325<br />
L 1325 Luxembourg<br />
Fax Fax : : (00352) (00352) 44 44 24 24 24 24-4506 24 4506<br />
Assurances.voyages@axa.lu<br />
Assurances.voyages@axa.lu<br />
LUXAIR LUXAIR reservation servation no no: no<br />
......................................................<br />
Contract n° : 27/0105912- TRAVEL PACKAGE<br />
1. Policy Policy holder holder<br />
2. Reimbursement Reimbursement by bank transfer<br />
Surname..............................................................................<br />
Christian name: .................................................................<br />
Date of birth: …... / …… / …………<br />
Address : ............................................................................<br />
Private tel.: .........................................................................<br />
Email : .................................................................................<br />
Profession : ........................................................................<br />
Office tel.: ...........................................................................<br />
Bank: ..................................................................................<br />
IBAN account No: ..............................................................<br />
BIC : ....................................................................................<br />
Account holder:<br />
Signature of beneficiary: ...................................................<br />
� Corresp Correspondence<br />
Corresp ondence : Please send all correspondence to the above mentioned Email address<br />
3. <strong>Travel</strong> <strong>Travel</strong> <strong>Travel</strong> information<br />
information<br />
information<br />
Destination: ........................................................................<br />
Date of reservation: / …… / …………<br />
Date of <strong>cancellation</strong>: / …… / …………<br />
4. Amount Amount <strong>claim</strong>ed <strong>claim</strong>ed<br />
<strong>claim</strong>ed<br />
Total travel costs: ............................................................€<br />
Cancellation fees: ............................................................€<br />
Amount to be reimbursed: ..............................................€<br />
5. Reason Reason for for for cancellati <strong>cancellation</strong><br />
cancellati on<br />
Maximum 180€<br />
Date of departure: …... / …… / …………<br />
Date of return: …... / …… / …………<br />
Airport tax reimbursed by the airline?<br />
���� Yes Yes<br />
���� Parti Partially Parti Parti ly<br />
���� No No<br />
No<br />
Amount: ........................................................................... €<br />
In case of sickness, accident or death please complete below the name of the affected person<br />
Full name: ...........................................................................<br />
Date of birth: …... / …… / …………<br />
Address : ..............................................................................<br />
.............................................................................................<br />
Please advise the reason for <strong>cancellation</strong> by completing the appropriate section below:<br />
Profession : ..........................................................................<br />
Office tel.: ............................................................................<br />
Private tel: ...........................................................................<br />
Email<br />
1-2
� Disease Disease: Disease<br />
When was the illness noticed?<br />
Date: …... / …… / …………<br />
When did the patient first consult a physician (due to<br />
this disease):<br />
Date: …... / …… / …………<br />
Is the patient currently at home?<br />
� Yes - � No<br />
� Accident Accident: Accident<br />
Place: ...........................................................................<br />
Date: …... / …… / …………<br />
Injuries:<br />
......................................................................................<br />
......................................................................................<br />
......................................................................................<br />
Detailed description of the circumstances:<br />
......................................................................................<br />
......................................................................................<br />
......................................................................................<br />
Is the patient currently at home?<br />
� Yes - � No<br />
� Loss Loss (d (death) (d ath) ath): ath)<br />
Date of Loss: …... / …… / …………<br />
Diagnosis:<br />
..............................................................................................<br />
..............................................................................................<br />
..............................................................................................<br />
..............................................................................................<br />
..............................................................................................<br />
..............................................................................................<br />
................................<br />
................................................................<br />
................................ ................................<br />
..........................................................<br />
................................ ..........................<br />
Is a third party liable: � Yes - � No<br />
Full name:<br />
..............................................................................................<br />
Address :<br />
..............................................................................................<br />
..............................................................................................<br />
..............................................................................................<br />
Name and address of his /her insurance company:<br />
..............................................................................................<br />
..............................................................................................<br />
..............................................................................................<br />
His / her insurance policy no:<br />
..............................................................................................<br />
Date of funeral: .....................................…... / …… / …………<br />
� Other reasons reasons (please give details):<br />
................................................................................................................................................................................................<br />
................................................................................................................................................................................................<br />
6. Parti Parties Parti Parties<br />
es affected affected by the the travel tha that tha<br />
t has been been cancelled, cancelled, delayed or that required an early return<br />
Full name<br />
Relationship to the person whose illness, accident or<br />
death lead to the <strong>cancellation</strong>, delayed departure or early<br />
return<br />
1) ......................................................................................... ..............................................................................................<br />
2) ......................................................................................... ..............................................................................................<br />
3) ......................................................................................... ..............................................................................................<br />
4) ......................................................................................... ..............................................................................................<br />
5) ......................................................................................... ..............................................................................................<br />
6) ......................................................................................... ..............................................................................................<br />
I hereby declare that all answers given in conjunction<br />
with this <strong>claim</strong> are true. Any intentional omission or<br />
misstatement could void AXA Assurances<br />
Luxembourg of its obligations..<br />
Signed in .................................. , on ...................................<br />
Please Please submit the following documents with with your your <strong>claim</strong> <strong>claim</strong>: <strong>claim</strong> :<br />
- Confirmation of travel reservation<br />
- Copy of the electronic tickets<br />
- LUXAIR’s reimbursement letter<br />
Signature Signature of <strong>claim</strong>ant <strong>claim</strong>ant<br />
preceded preceded by by “read “read and and approved” approved”<br />
approved”<br />
Kindly Kindly provide provide as soon as as possible possible, possible<br />
, in case case of of: of<br />
:<br />
• Disease, accident or pregnancy:<br />
• a medical report (using the attached form)<br />
� Loss: a death certificate<br />
� Other reasons: official documents justifying the <strong>claim</strong><br />
AXA AXA AXA Assurances Assurances Luxembourg<br />
Luxembourg<br />
Luxembourg<br />
Société anonyme - 7, rue de la Chapelle L <strong>–</strong> 1325 Luxembourg <strong>–</strong> R.C. Luxembourg : B 53466<br />
2-2
MEDICAL MEDICAL REPORT ORT<br />
ORT/ AXA Assurances Luxembourg<br />
To be completed by your GP Secrétariat Secrétariat médical<br />
médical<br />
Please Please send send in in a sealed envelope envelope to :<br />
7 7 Rue Rue de de la la Chapelle<br />
Chapelle<br />
L- 1325 Luxembourg<br />
Luxembourg<br />
LUXAIR LUXAIR reservation servation number<br />
number: ...............................................................................................................................<br />
Patient’s full name: Date of birth: …... / …… / …………<br />
Address: Date of exam: .... …... / …… / …………<br />
Reaso Reason: Reaso<br />
: � Disease<br />
� Accident<br />
� Pregnancy<br />
1. Detailed description of diagnosis (nature of the disease and symptoms):<br />
.................................................................................................................................................................................................<br />
.................................................................................................................................................................................................<br />
2. Date of first medical consultation: …... / …… / …………<br />
3. Treatment : .............................................................................................................................................................................<br />
.................................................................................................................................................................................................<br />
4. Special exams? Please specify details and date(s). ............................................................................................................<br />
5. Prescribed medication: ..........................................................................................................................................................<br />
6. Duration and frequency of treatment and of medication: ...................................................................................................<br />
7. Date of last medical consultation: …... / …… / ………… Reason ..........................................................................................<br />
8. Has the patient been affected for some time by this disease? � yes � no<br />
If yes, since when? …... / …… / ………… Duration of treatment: ..........................................................................................<br />
- has their health worsened? � yes � no<br />
9. Has the patient been advised not to undertake or not to continue the journey? � yes � no<br />
If yes, when? …... / …… / ………… Why? ................................................................................................................................<br />
10. As a consequence, has there been an interruption of their current activities?<br />
� yes � no du …... / …… / ………… au …... / …… / …………<br />
11. Is the patient authorised to leave his home? � yes � no from …... / …… / ………… until …... / …… / …………<br />
12. Has the patient been or will be hospitalised? � yes � no from …... / …… / ………… until …... / …… / …………<br />
13. Medical history : .....................................................................................................................................................................<br />
Surgical history: ......................................................................................................................................................................<br />
14. In case of a pregnancy, estimated date of birth? …... / …… / …………<br />
15. Other comments: ....................................................................................................................................................................<br />
.................................................................................................................................................................................................<br />
Signed in...................................., on …... / …… / …………<br />
Certifi Certified Certifi<br />
ed true and sincere sincere, sincere<br />
Stamp Stamp Stamp and and and signature signature of of physician<br />
physician<br />
The The <strong>claim</strong>ant <strong>claim</strong>ant has has to to assume assume all all fees fees in in relation relation with with the the medical consultation<br />
consultation necessary to complete this form form.<br />
form<br />
AXA AXA AXA Assurances Assurances Luxembourg<br />
Luxembourg<br />
Luxembourg<br />
Société anonyme - 7, rue de la Chapelle L <strong>–</strong> 1325 Luxembourg <strong>–</strong> R.C. Luxembourg : B 53466
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