TicketPlan Protection Refund Application Form

Transcription

1 TicketPlan Protection Refund Application Form Instructions for Ticketholder 1 2 Please complete your details in BLOCK CAPITALS. After completing the form please forward it to: TicketPlan, Leigh House, Broadway West, Leigh On Sea, Essex, SS9 2DD 3 All refund applications must be made as soon as reasonably possible after becoming aware of circumstances that may lead to a refund application BOOKING REFUND PROTECTION IS AN OPTIONAL SERVICE OFFERED BY THE BOOKING VENDOR AND ADMINISTERED BY TICKETPLAN ON THEIR BEHALF. IT IS NOT AN INSURANCE POLICY. Please ensure that you enclose the following documentation (copies may be acceptable) in support of your refund application (where appropriate only) Original unused tickets where applicable. Confirmation of your payment for TicketPlan Protection. (your booking confirmation) For applications relating to illness or injury, please complete the enclosed medical confirmation form. Submission of our own medical confirmation form is preferred. We will consider other medical documents but these may not be adequate for our needs. Death certificate. (please do not send original certificates) Evidence of breakdown or disruption to public transport. Evidence of breakdown of private transport. Evidence of the Emergency Services attending your residence in the event of burglary or fire. Original witness summons instructing you to appear in court. Original invitation to attend jury service. Original advice of cancellation of leave/advice to travel at short notice on military service. Print out from Met Office website/confirmation of Police Warning for weather applications. Any other reasonable documentary evidence that might be required. FAILURE TO PROVIDE APPROPRIATE DOCUMENTARY VERIFICATION MAY MEAN THAT YOUR APPLICATION IS INADMISSIBLE The ticketholder (the person who has purchased Cancellation Protection) must answer all questions below. Please answer all questions clearly and concisely to avoid misunderstanding or delay. (Add further details on additional sheets if required) 1. Your Details Title... Initials... Surname... Address... Address... Postcode... Telephone (home/mobile)... Address Details of booking (include Package details if relevant) Date of purchase... Venue... Booking reference No.... Ticket Vendor (who you purchased the tickets from)... Event/Part(s) of Package... Date(s) of Event/Part(s) of Package... Cost of tickets/part(s) of package that are the subject of this refund application... Cost of booking fee... Cost of TicketPlan Protection... Number of ALL persons due to attend Event/Part(s) of package... Names of ALL persons due to attend Event/Part(s) of package... Number of ALL persons unable to attend Event/Part(s) of package Names of ALL persons unable to attend Event/Part(s) of package When did you become aware that you were unable to attend the Event/Part(s) of package?... 1

2 3. Refund Application Details Please complete the section which is relevant to your application. A. Injury/Illness - Please be advised we will require a completed medical confirmation form (enclosed). Submission of our own medical confirmation form is preferred. We will consider other medical documents but these may not be adequate for our needs. Identity of the person who suffered the injury/illness... If this person was not attending the event/parts of package please indicate their relationship to you Nature of injury/illness... When/how injury occurred... Date on which medical attention was first sought for illness/injury?... Why did the injury/illness prevent this person from attending the Event/Part(s) of the Package? B. Bereavement - Please be advised we will require a copy of the death certificate to be enclosed. Please do not send the original certificate. Identity of the deceased... If not attending the event/part(s) of package with you please indicate their relationship to you Date and cause of death... When was medical advice/treatment first sought for the medical condition causing death? C. Unexpected disruption of the public transport network - Please note we will require official notification of the disruption issued by the service provider. Details of the planned journey Please give details of the cause of the disruption and how your journey was affected D. Breakdown, accident, fire or theft of Private vehicle - Please note we will require a vehicle recovery service report, incident report or copy of garage repair bill to be enclosed as appropriate. Details of vehicle concerned Details of planned journey Details of when you left home Location of incident Date and time of incident Details of incident 2

3 Please tick as appropriate E. Jur y Service Please note we will require a copy of the original invitation to attend jury service. F. Burglary or fire at your residence Please note we will require evidence of the Emergency Services attending your residence in the event of burglary or fire. G. Witness summons for court proceedings Please note we will require a copy of the Original witness summons instructing you to appear in court. H. Armed Forces call up/cancellation of leave Please note we will require a copy of the Original advice of cancellation of leave/ advice to travel at short notice in relation to military service. I. Adverse Weather Please note we will require a screen grab/scanned print out from the Met Office website/confirmation of Police Warning. J. Other Please provide details below and attach supporting documentation as appropriate. PLEASE NOTE: The Booking Refund Protection service only provides a refund following a cancellation that results from specific/listed circumstances and is subject to the Terms and Conditions provided at the time of purchase. If you are applying as a result of a circumstance that is not listed, it is likely that your application will fall outside the scope of the Booking Refund Protection service Please ensure that you have provided all requested supporting documentation. We are unable to process any refund applications which are not fully documented. FAILURE TO PROVIDE APPROPRIATE DOCUMENTARY VERIFICATION MAY MEAN THAT YOUR APPLICATION IS INADMISSIBLE 3

4 In submitting this form I declare that the information I have provided above is true to the best of my knowledge. Any refund made as a result of any knowingly incorrect statement made by me or on my behalf shall be invalid and may result in subsequent action being taken against me. I agree that any copy made of this form shall have the validity of the original. I agree to the use of my data (including any sensitive personal data) submitted as part of this refund application form being used in accordance with the Data Protection Notification below and I confirm that I have the consent of any applicable persons due to attend the event with me whose data I am submitting as part of this refund application form in regards to the same. Ticketholder Signature...Date... Address... Refund Payment Ideally we would like to credit funds directly in to your Bank Account. Please note we are unable to refund using credit/debit card details. Could the ticketholder please provide the following details: Bankers... Sort Code Account No.... Account Name... TicketPlan cannot be held responsible if incorrect banking details are provided. Please note: The account holder is liable for bank charges levied by the receiving bank. Data Protection Notification. TicketPlan Limited ( We, us, our ) may transfer your own and any applicable persons information (including sensitive personal data) to third parties for the purpose of Cancellation Protection. If we do this we will ensure that anyone to whom we pass it provides an adequate level of protection. We and our third parties may also receive such information relating to you and any member of a group due to attend an event with the ticketholder from the booking vendor for the purpose of Cancellation Protection. By proceeding with an application for a refund it will signify your own and any group members consent to such information being processed by us and such third parties. Information (including sensitive personal data) you and/or any group members supply in applying for a refund may be shared with and used by our refund administrators, the booking vendors insurers, their associated companies and agents and the booking vendor. It may be disclosed to regulatory bodies for the purposes of monitoring and/ or enforcing the insurers compliance with any regulatory rules/codes. Such information may also be used for research and statistical purposes and crime prevention. Such information may be transferred to any country, including countries outside the European Economic Area for any of these purposes and for systems administration. If you and/or any group members give us information (including sensitive personal data) about another person when applying for a refund, in doing so you confirm that they have given permission to provide it to us and for us to be able to process their personal data (including any sensitive personal data) and that you and/or any group members have told them who we are and what we will use their data for as set out in this notice. In assessing any refunds, Third Parties, such as Fraud Investigators may undertake checks against publicly available information (such as electoral roll, county court judgments, bankruptcy orders or repossessions). Information (including sensitive personal data) may also be shared with other insurers either directly or via those acting for the insurer (such as fraud investigators). If you and/or any group members want us to remove any personal information from our records please write to us at, TicketPlan Ltd, Leigh House, Broadway West, Leigh On Sea, Essex, SS9 2DD. We will make all reasonable efforts to delete such information from our records if it is appropriate in accordance with the provisions of the Data Protection Act You can ask us for a copy of the information we hold about you at anytime (for which we may charge a small fee which is currently 10.00) by contacting us at TicketPlan Ltd, Leigh House, Broadway West, Leigh On Sea, Essex, SS9 2DD. TP/REFAPP/

5 Administered by MEDICAL CONFIRMATION PATIENT PLEASE ENSURE THAT YOU PRE-COMPLETE FIELDS A-C (BELOW) PRIOR TO SUBMITTING THIS FORM TO YOUR GP. GP PLEASE ENSURE THAT ALL SECTIONS HAVE BEEN COMPLETED AND THAT THE CERTIFICATE IS STAMPED BEFORE RETURNING IT TO THE PATIENT. Patient (A to C below to be completed by Patient before submitting to the GP) A. Name of patient:. B. Date of booking your tickets:. C. Date of event/travel. GP (D and E below to be completed by GP after the above has been completed by the Patient) D. Date of first consultation for this specific illness/injury:.. E. Details of illness/injury:. I confirm that this patient did consult with me in relation to this specific illness/injury on the date shown above and that medical advice or treatment was not sought for this illness/injury or any related or potentially related illness/injury in the 12 months prior to the above date of booking. In my medical opinion and as a direct and specific result of the condition mentioned above, the patient is/was unfit to travel/attend the booked event on the date shown above. GP Name:.. GP Signature:.. Date: Surgery Stamp: TP/MEDCERT/180117