Please prepare the documents needed for your claim

Choose this form if you want to claim reimbursement of costs incurred due to an illness or accident abroad.

Police, fire brigade or other emergency services report, if their intervention was required
Witness statements
Death certificate, death record and statistical death card, or another document specifying the cause of death
Other documents confirming the validity of the claim

Reporter details

Fill the form with random test data

Firstname

Lastname

E-mail address

Country code, e.g. 48

Mobile phone number

Date of birth

Sex

woman man I prefer not to give

Country

City

Street and house/flat number

Zip code

Is the claimant also the insured?

yes no

A claim can be made by an injured adult or his/her parent/legal guardian if the injured party is a minor.

Injured party details

Firstname (of the injured party)

Lastname (of the injured party)

Date of birth (of the injured party)