SUBJET: REIMBURSMENT COMPENSATION FORM

Transcription

1 FILE NUMBER: Mr./Ms. SUBJET: REIMBURSMENT COMPENSATION FORM Dear Insured, IN CASE OF APPLICATIONS FOR REIMBURSEMENT: All documentation should be sent to: 1. Option: if your original documents are electronic (invoices, bills...) you can send them via to with the above subject, "Pullmantur Reimbursement ID / Passport or Booking number" 2. Option: If your originals are NOT electronic send all documents to: MAPFRE ASISTENCIA Reference: PULLMANTUR Reembolsos Carretera de Pozuelo, nº 52 Edificio anexo Majadahonda Madrid - España If you need additional information about your file status we recommend you to call to our Contact Phone: (service hours from Monday to Friday 9-17h / except holidays) IT IS ESSENTIAL FOR THE PROCESS TO SEND THE ORIGINAL DOCUMENTS, HOWEVER KEEP A COPY FOR YOUR PERSONAL RECORDS. The company has the right to request additional information for the proper processing of the file and to CLOSE THE ONGOING FILE due to the lack of documentation. The present form is NOT recognition of coverage of the incident nevertheless will be used by the insurer to analyze the incident, with the understanding that in accordance with the terms and conditions of the insurance policy, the insurance company may reject the claim. Kindest regards, Signed: Direct Phone: masist.reembolsos@mapfre.com Reimbursement Department MAPFRE FAMILIAR

2 REIMBURSMENT COMPENSATION FORM POLICY Nº FILE Nº BOOKING Nº TRAVEL DATES (TO AND FROM) DESTINATION AND ITINERARY TRAVEL AGENCY / AGENT INFORMATION INSURED INFORMATION Name and Surname ID / Residence Card / Passport Holder number Address Contact Telephone Name of bank account holder ID number of the bank account holder Data bank account (including details for international transfers IBAN, SWIFT / BIC) Account bank holder signature COVERAGE TYPE Based on the contracted hedges in your policy Travel Assistance Luggage and delays Cancellation / Interruption Medical Expenses Transport or repatriation Extended stay due to illness / accident Early Return Theft, loss, damage luggage (underline the correct answer) Delayed luggage delivery Travel Delay Cancellation expenses Travel Interruption Personal Injuries Demise Permanent Disability Civil Liability Private Civil Liability Legal Expenses

3 REQUIRED DOCUMENTATION For all applications (along with this completed form) 1. Send copy of the policy certifying inclusion, payment, insurance contract and initial date. Send total cost of the insured trip and travel voucher, if applicable. For trips covered by insurance through card, attach a copy of the card and the proof of payment. 2. Send the proof of travel dates and destination. 3. Send the copy of the reimbursement applicant ID, and a copy of the account bank holder ID, if differs from the first. 4. In case you have involved family members, please send kinship certificate. 5. Send account of the facts. Recommended explanatory letter. 6. Other supporting documents required. According to the type of coverage: A. PERSONAL ASSISTANCE Medical expenses reimbursement: - Send the report of the original medical care referring the reason of illness, accident, hospitalization, diagnosis and the exact date of occurrence. - Send the original invoice of medical services. Transportation and medical repatriation or demise reimbursement: - Send original tickets/proof of used means of transportation. - Send original tickets/proof of unused means of transportation planned for the return. - Demise Certificate, if applicable. Extended stay reimbursement - Original itemized hotel invoice. Travel and companion accommodation reimbursement - Send original tickets/proof of used means of transportation and original itemized hotel invoice. Early return of Insured reimbursement - Send the copy of electronic tickets used for the early return and its original invoice. - Send original invoices for other services that have been used regarding the anticipated return. - Justification of the occurrence of the incident which has caused the early return 1. In case of early return for serious family illness detailed medical report from the person originating the early return is required. 2. In case of early return due to demise, please send copy of the death certificate and a copy of kinship certificate 3. In case of early return for serious disaster at your habitual residence or professionals premises, please send documents or certificates of the fact that led to the interruption of the trip. Reimbursement of expenses for the acquisition of documentation - Send the document certifying the loss of passport (stolen report / lost, proof of emission of the new document, etc.) - Send original invoices of travel expenses and / or accommodation costs incurred as a result of the occurrence with the passport. B. IMPLICATIONS FOR THE DELAY OF CONTRACT MEANS OF TRANSPORT AND LOSS OF SERVICES - Flight delay Connection loss - Overbooking Cancelation - Send the certificate of the carrier for the incidence, reflecting the type of incident and the cause thereof. - Send the copy of the tickets. - Send original invoices for the expenses incurred as a result of the occurrence with the carrier. C. LUGGAGE COVER Checked luggage - Send original document issued by the carrier certifying the occurrence (PIR and / or certificate of irregularity according to the cause, and / or complaint / police report. - In case of theft or loss: Send invoices or bank statements showing the purchase of stolen / lost property or, alternatively a list of the contents of the luggage. - Send the list and assessment of luggage contents - In case of delayed luggage delivery: Send the proof luggage reception - Proof of compensation from the carrier with the concept of the proposed cause. Unchecked luggage - Send police report at the place of occurrence of theft - Send list and invoices of the stolen items - Send claim under the shipping company. D. CANCELATION / INTERRUPTION Trip cancellation (including cruises) - Send the copy of the tour program showing all contracted services, cost and conditions of sale/cancellation. - The copy of the booking cancellation with the incurred costs - The original invoice issued by the retail customer for the cancellation expenses or, failing that, - the original invoice for full travel payment and the original invoice of the portion refunded for by your travel agent. Airline tickets cancellation - Tickets: physical or electronic document - Airfare terms (policy changes and refunds) - Booking history stating the cancellation - Reimbursed amount invoice paid by the airline/travel agency Trip Interruption - Send the carrier certificate reflecting the real departure time - The information about the original flight plan - The copy of travel payment invoice

4 - And the justification of wholesale with the breakdown of the lost services Loss of contracted services: Loss of classes and ski pass: - Send the repatriation proof - Sky pass: individual original proof of the paiment made to the travel agency or ski school for the amount of the class or pass. - Medical report indicating the fact that did not allow the participation of the insured in such activities. ATTENTION: If you cancel or interrupt your trip for medical reasons you must deliver and complete the following information: A stamped and signed medical report detailing the injury or illness (including description of the medical history of the patient regarding the condition that led to the submission of application for compensation if any) and in which, moreover, is answer the following questions: Date of onset of symptoms: Date of first appointment: Issue date of diagnosis - If beneficiaries are the heirs of the insured send a copy of the deed of partition and adjudication of inheritance or, if applicable, the order of declaration of heirs issued by the competent court - Acquaintance or exemption from Inheritance Tax duly completed by the corresponding tax Office Civil Liability: - Certificate of Insurance / Travel Pass / Justification of insurance with Mapfre - Original invoices for the requested amounts - Other party involved complaint F. OTHER CAUSES If you need to claim any other incident that is not in the sections listed above, please indicate here the circumstances and details of the incident. If space is insufficient, please attach a separate explanatory sheet. E. ACCIDENTS, CIVIL LIABILITY, LEGAL EXPENSES Demise: - Send the birth certificate and demise certificate of the insured - The documents attesting the beneficiaries

5 STATEMENT OF EXPENSES Date Invoice concept Amount Currency Very important: please fill in the box with the list of expenses for the requested reimbursement (if necessary you can attach a separate sheet) In case the facts stated are not true, the insured lose entitlement to compensation and the insurer may take the measures it deems appropriate. The undersigned hereby declares that the statements made herein are true and undertakes to submit the documentation required by the Insurer. Date and Signature of the Insured REMEMBER: APPLICATIONS MUST INCLUDE THE VAT NUMBER OF THE PERSON WHO RECEIVE THE PAYMENT AND SIGNED BY THE INSURED The above described insured authorizes the processing of personal data supplied voluntarily through this document and its update for the fulfillment of the insurance contract itself and the payment of the corresponding compensation. Furthermore agree that the personal data is ceded, exclusively to those persons or entities whose intervention is necessary for the development of the purposes stated above as well as the policyholder insurance, without need to communicate each first assignment made to assignees. All data processed is confidential, not accessible to third parties for any other purposes that the ones for which they have been authorized. The created file is located in Ctra. de Pozuelo nº 50, Majadahonda (Madrid), under the supervision and control of MAPFRE FAMILIAR, COMPAÑÍA DE SEGUROS Y REASEGUROS, S.A., who assumes the adoption of technical security and organizational measures to protect the confidentiality and integrity of information, in accordance with the provisions of the Organic Law 15/1999, of September 13th, of the protection of Personal Data and other applicable legislation and to whom the owner of the data can exercise their rights of access, rectification, opposition and cancellation of their personal data provided by a written communication.