Policy details

Policy no.:

Policy holder/Company name:

Email address:

Phone no.:
Only numbers may be entered in this field.

Claimant’s name:

Gender:

Incident date:

Format: mm-dd-yyyy

Incident Description (In case of loss of baggage or theft, police report is mandatory)

When and where was the property last seen by you?

Format: mm-dd-yyyy

Time:

Place:

Was the incident reported to the police?

Is there any other insurance covering the same property?

Departure date:

Format: mm-dd-yyyy

Departure time:

Departure airport:

Arrival date:

Format: mm-dd-yyyy

Arrival time:

Arrival airport:

Reason for the fight cancellation/delay:

Number of hours the flight/baggage was delayed by:
Only numbers may be entered in this field.

Please provide a brief description of the incident:

Medical expenses

Do you have any health insurance?

Type of medical emergency:

Claim amount:

Type of treatment:

Have you previously suffered of the above injury/illness:

Please provide the details of the treatment received:

Bank details

Beneficiary name:

IBAN:
Only numbers may be entered in this field.

Policy holder declaration

I declare that I have become eligible to make a claim under the terms of my policy and claim benefit accordingly. I certify that, to the best of my knowledge, the above information is true and correct.
I understand that if any information provided by me is found to be deliberately misleading or incorrect, this claim may be rejected and my Policy may be treated as invalid. In such circumstances, I also understand that I will have to repay any benefit that I have received to date and that legal action could be taken against me.
I authorise AXA to make any enquires and obtain any information they consider relevant from any doctor(s), employer(s), ex-employer(s) or elsewhere. I understand that I must provide evidence to AXA to prove my claim. I understand and give explicit consent that the sensitive health and other information I may provide about myself will be used, stored, transferred and/or disclosed by AXA, its agents and associated companies, other insurers, regulators, industry, and public bodies (including the police) and agencies to process this insurance and any other insurance, handle claims and prevent fraud. This may involve the transfer of such information to other countries.
AXA has taken steps to ensure that your information is held securely. You have the right to access your personal data held by AXA. If you believe that your personal data held by AXA is inaccurate you have the right to ask for this to be rectified.
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