Reporter and type of claim

Please fill in a separate Claim form for each claim (e.g. one illness/one accident/one health care incident), if you want to claim compensation for several different illnesses, accidents or other claims. This is how you will ensure that claim handling is fluent.
We deal with the personal data of our customers in compliance with current insurance and data
protection laws. For more information on handling personal information, visit:

Type of claim

I claim compensation from: *

Type of claim: *


If you fill in the form on behalf of some other person (the Insured), provide your own contact details in this section. If you fill in the claim form as a representative of a company, provide the company’s name too.
Last name *
First name *
If you are also the Insured, you can select these options, and your contact details will be automatically added to these sections.
Claim reporter is also: