TRAVEL CANCELLATION – ING VISA GOLD / ING

TRAVEL CANCELLATION – ING VISA GOLD / ING MASTERCARD GOLD
CLAIMS NOTIFICATION FORM (Page 1 of 4) - Policy 2.040.114
GENERAL INFORMATION
Insurer:
Chartis
11, Boulevard de la Plaine
B-1050 Bruxelles - Belgique
: +32 2 739 91 04
: [email protected]
Cardholder ING Visa Gold or ING MasterCard Gold (ING Gold) (name and address):
_________________________________________________________________________________
_________________________________________________________________________________
ING Gold card number: ffff-ffxx - xxxx - xxxx
•
Insured
• Surname and Last Name : __________________________________________________
•
Address : _______________________________________________________________
_______________________________________________________________________
•
Date of Birth : ff
/ ff / ffff
•
Telephone home / office : __________________________________________________
•
E-mail : ________________________________________________________________
REIMBURSEMENT
Reimbursement (cf. Terms and Conditions of the Insurance)
•
Bank account number: fff-fffffff-ff
•
SWIFT (BIC) :___________________________________________________________
•
IBAN : _________________________________________________________________
(International Banking Account Number)
•
Name and address of the bank :
__________________________________________
__________________________________________
Chartis Europe S.A. – Belgian Branch, Boulevard de la Plaine 11 - B-1050 Bruxelles - Tél. +32 2 739 90 00 - Facsimile +32 2 739 91 02 - RPM Bruxelles
0435 262 754. Chartis Europe S.A.is a "Société Anonyme" incorporated under the laws of France having its registered offices in Tour Chartis ,
Paris La Défense, 34 Place des Corolles, 92400 Courbevoie, France, R.C.S. Nanterre n° 552 128 795.
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TRAVEL CANCELLATION – ING VISA GOLD / ING MASTERCARD GOLD
CLAIMS NOTIFICATION FORM (Page 2 of 4) - Policy 2.040.114
CLAIM
(to be duly completed by the ING Gold Cardholder)
•
Date of the loss: ff
/ ff / ffff
•
Circumstances and location of the loss:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
•
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?
_______________________________________________________________________
_______________________________________________________________________
Personal data: your personal data (hereinafter the "Data") will be processed in accordance with the law 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 fraud
prevention.
To achieve these objectives, the Insurer may be required to transfer Data to other companies of the Chartis group, to
sub-contractors or to partners. These companies, subcontractors or partners may be located in countries outside the
European Economic Area that do not necessarily offer the same level of protection as Belgium. The Insurer shall take
all precautionary measures to ensure the protection of Data. However, the Insurer cannot avoid all risks related to
the processing of Data.
According to the law, the Insured is entitled to access, amend or oppose (for a reasonable cause) to
the processing of Data relating to him. To exercise these rights, the Insured can contact the Insurer at any time in
writing at Blvd de la Plaine 11, 1050 Brussels.
In as far as necessary and in particular in respect of health related data, the Insured approves the processing and the
transfer of the Data within the limits and under the conditions described here above.
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
Please send this claim form together with all required substantiating documents as soon as possible to Chartis Claims Department, Boulevard de la Plaine 11, 1050 Bruxelles.
Chartis Europe S.A. – Belgian Branch, Boulevard de la Plaine 11 - B-1050 Bruxelles - Tél. +32 2 739 90 00 - Facsimile +32 2 739 91 02 - RPM Bruxelles
0435 262 754. Chartis Europe S.A.is a "Société Anonyme" incorporated under the laws of France having its registered offices in Tour Chartis ,
Paris La Défense, 34 Place des Corolles, 92400 Courbevoie, France, R.C.S. Nanterre n° 552 128 795.
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TRAVEL CANCELLATION – ING VISA GOLD / ING MASTERCARD GOLD
CLAIMS NOTIFICATION FORM (Page 3 of 4) - Policy 2.040.114
PROOF OF LOSS DOCUMENTS – TRAVEL CANCELLATION
•
Date of travel reservation :
•
Date of cancellation : ff
•
ff / ff / ffff
/ ff / ffff
Amount of the claim: f.fff,ff €
(Please see the « Calculation of Travel Cancellation Costs » on the next page)
Documents to be enclosed with this present notification:
In all cases, the proof that the payment of the Insured Trip was made with the Card.
- In case of a trip cancellation:
•
confirmation of the trip reservation,
•
proof of the cancellation.
- In case of trip interruption:
•
confirmation of the trip reservation,
•
declaration of the travel agency confirming the number of non-used days.
- In case of Death: death certificate.
- In case of Sickness: medical certificate.
- In case of Major Property Damage: document certifying the events from local authorities (police report,
firemen declaration, etc).
- In case of Theft of Travel Documents: copy of police report and PV-number.
Personal data: your personal data (hereinafter the "Data") will be processed in accordance with the law 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 fraud
prevention.
To achieve these objectives, the Insurer may be required to transfer Data to other companies of the Chartis group, to
sub-contractors or to partners. These companies, subcontractors or partners may be located in countries outside the
European Economic Area that do not necessarily offer the same level of protection as Belgium. The Insurer shall take
all precautionary measures to ensure the protection of Data. However, the Insurer cannot avoid all risks related to
the processing of Data.
According to the law, the Insured is entitled to access, amend or oppose (for a reasonable cause) to
the processing of Data relating to him. To exercise these rights, the Insured can contact the Insurer at any time in
writing at Blvd de la Plaine 11, 1050 Brussels.
In as far as necessary and in particular in respect of health related data, the Insured approves the processing and the
transfer of the Data within the limits and under the conditions described here above.
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. The undersigned herewith authorises the
company to recover the expenses from a liable third party.
Date + signature of the Insured
Please send this claim form together with all required substantiating documents as soon as possible to Chartis Claims Department, Boulevard de la Plaine 11, 1050 Bruxelles.
Chartis Europe S.A. – Belgian Branch, Boulevard de la Plaine 11 - B-1050 Bruxelles - Tél. +32 2 739 90 00 - Facsimile +32 2 739 91 02 - RPM Bruxelles
0435 262 754. Chartis Europe S.A.is a "Société Anonyme" incorporated under the laws of France having its registered offices in Tour Chartis ,
Paris La Défense, 34 Place des Corolles, 92400 Courbevoie, France, R.C.S. Nanterre n° 552 128 795.
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TRAVEL CANCELLATION – ING VISA GOLD / ING MASTERCARD GOLD
CLAIMS NOTIFICATION FORM (Page 4 of 4) - Policy 2.040.114
Chartis Europe S.A. – Belgian Branch, Boulevard de la Plaine 11 - B-1050 Bruxelles - Tél. +32 2 739 90 00 - Facsimile +32 2 739 91 02 - RPM Bruxelles
0435 262 754. Chartis Europe S.A.is a "Société Anonyme" incorporated under the laws of France having its registered offices in Tour Chartis ,
Paris La Défense, 34 Place des Corolles, 92400 Courbevoie, France, R.C.S. Nanterre n° 552 128 795.
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