INTERNATIONAL PASSENGER PROTECTION LTD IPP House, Station Rd, West Wickham, Kent, BR4 0PR Tel: / Fax:
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1 2438 INTERNATIONAL PASSENGER PROTECTION LTD IPP House, Station Rd, West Wickham, Kent, BR4 0PR Tel: / Fax: FINANCIAL FAILURE OF TOUR ORGANISER CLAIM FORM Name: Address: Telephone: Facsimile: Post Code: DETAILS OF CLAIM Name(s) of Passengers If more than 10 passengers, please use back page.
2 TOUR ORGANISER DETAILS Original Departure Date Destination Original Actual Return Date Return Date Date of Booking Booked Through NAME OF TOUR ORGANISER FAILED DATE TOUR ORGANISER FAILED Type of Claim (please tick) Deposit Only [ ] Full Payment [ ] Repatriation or Continuation of Journey [ ] Total Claimed For persons listed. Have you claimed or are you able to claim these monies from any other source YES / NO If yes, please explain...
3 METHOD OF PAYMENT FOR TICKETS - Please complete sections a), b), c) or d) A) Payment by Credit Card direct to airline/ supplier: Name of cardholder Card type (Please select one of the following): MasterCard [ ] VISA [ ] If other, please state: Card number: (Please only state the first and last 4 digits) Expiry date Please tick this box if your card holds the visa symbol [ ] Please tick this box if your card holds the mastercard symbol [ ] b) Payment by Debit Card direct to airline/ supplier: Name of cardholder Card type (Please select one of the following): Visa [ ] Maestro [ ] Solo [ ] Switch [ ] If other, please state: Card number: (Please only state the first and last 4 digits) Expiry date Please tick this box if your card holds the visa symbol [ ] Please tick this box if your card holds the mastercard symbol [ ] c) Payment by cheque: Payable to d) Other method: Please provide details:
4 STATEMENT OF SUBROGATION (This section legally allows your claim, when paid, to be transferred to the insurers.) In consideration of you paying to us the sum of by way of indemnity, We assign to you all rights, claims and interest that we may have against the failure of... to International Passenger Protection Ltd, as agents for their Principals Signed... Date... Name... Position... DECLARATION I declare that to the best of my knowledge and belief all facts are correct. I also declare that I had no knowledge of the potential failure at the time of the booking as detailed. Signed... Date... Name... DOCUMENTS REQUIRED TO SUBSTANTIATE CLAIM(S) We enclose the following original documents (please tick) 1. Unused Airline Ticket(s) / Vouchers [ ] 2. Evidence of Payment(s) (cancelled cheque etc) COPY OF CHEQUE/VISA DEBIT/CREDIT CARD STATEMENTS [ ] 3. Confirmation and Invoice [ ] 4. Receipts / evidence of payment relevant to onward or return transportation [ ] 5. Certificate of Insurance [ ] Failure to provide these original documents may jeopardize your claim.
5 PLEASE LIST PASSENGER NAMES HERE IF MORE THAN REMARKS Compliance with the Data Protection Act 1998 We hereby notify you that any personal data obtained about you will be processed in accordance with the Data Protection Act By signing this form, you confirm that you have obtained the consent of all individuals named on this form, to their data being stored and processed by IPP in accordance with the Act and such information will only be held in the respect of dealing with your claim. Tour Op Claim Form Aug. 2017
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