Claim form non-medical expenses

This form consists of 3 pages and can be used for several types of insurance. For further instructions turn
to the backside of the form. Please fill in all the requested details and make a copy for your own
administration. You kan download a new form on www.aonstudentinsurance.com.

Type of insurance

(tick the correct box)

Household contents: question 1 t/m 5 + 6 t/m 8 + 12

Travel/baggage: question 1 t/m 5 + 11 t/m 12

Liability: question 1 t/m 5 + 9 t/m 10

Extra costs (flight costs): question 13

Policy number ____________________________________________________________

Policyholder

Manager of affairs in the Netherlands

Name _____________________________________________ Name _____________________________________________

Address ___________________________________________ Address ___________________________________________
Place of residence ___________________________________ Place of residence ___________________________________
Telephone _________________________________________ Telephone _________________________________________
E-mail _____________________________________________ E-mail ____________________________________________
(Post)bank number _________________________________ (Post)bank number _________________________________

1. Report damage
Has the damage/loss already been reported?

Yes, when? _____________________

No

2. Other insurance
Are you insured elsewhere that might cover these costs?

Yes

No

Insurance company _________________________________ Policy number _____________________________________

Type of insurance ___________________________________ Insured sum _______________________________________
Have you reported the damage/loss with the insurance company?

Yes

No

Are certain objects such as jewelry, instruments and other valuables insured separately?

Yes

No

3. Particulars of claim
Date of damage/loss

Day ________ Month ________________ Year ___________

Place/address of damage/loss ___________________________________________

(state location for example, kitchen, garden etc.)

For particular damaged or lost goods see question 6

4. Police report
Have you reported the loss to the police?

Yes

No

If not, what is the reason? _________________________________________________________________________________

5. Repair
Is the damage going to be repaired?

Yes, for what amount? ______________________

No

Has the reparation already been performed?

Yes, for what amount? ______________________

No

(Please attach invoice or estimate of the costs)

6. Cause of damage
How was the damage caused?
Fire

Traffic

Scorch/Singed/Melt

Storm

Vandalism

Stroke of lightning

Precipitation

Other,

Theft/Robbery

Rapture water-mains

Explosion

(breaking and entering)

Yes

Was there sign of forcible entry?

_______________

No

Cause of damage
Description of the occurrence

(If necessary attach a sketch and/or statement separately)

________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________

7. By whom was the damage made?

Name, address and birth date ____________________________________________________________________________
What is the relationship? ____________________________________________________________

(Family, work relationship etc.)

With what was the damaged caused? ______________________________________________________________________

What were the above mentioned doing? ___________________________________________________________________
When the damaged was caused? ___________________________________________________________________________

8. Witnesses
Were there witnesses to the event?

Yes

No

If so, state full name(s) and addresses

(please use a separate paper)

9. Damage to third party (Liability)

I t i s a b s o l u te l y n e c e s s a r y t h a t yo u s e n d a l l c o r re s p o n d e n c e b e t we e n p a r t i e s
What kind of damage was inflicted?
Who is the third party?

Material

Personal

Name/address _______________________________________________________________
(Post)bank number ___________________________________________________________

Is the third party insured for the concerning damage?

Yes

No

If so, which insurance company? ___________________________________ Policy number ________________________

10. Redress
Are you of opinion that the damage can be redressed?

Yes

No

If so, state full name, address, e-mail, telephone _____________________________________________________________

________________________________________________________________________________________________________

11. Travel/Baggage
Where and under which circumstances did the damage occur? _________________________________________________
________________________________________________________________________________________________________
Cause of damage? (see also question 7) _________________________________________________________________________
Has the airline company/hotel management been informed of the damage/loss?

Yes

No

Please enclose all formal reports of the damage/loss.

12. Particulars damaged or lost goods (enclose purchase/repair receipts)

Brand, type, name

Date of purchase

Price of purchase

Repair costs

________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________

13. Extra costs (flight costs)

What was the reason for the flight costs?

Decease of blood relative 1st and 2nd degree (enclose death certificate)
In peril of death (enclose medical statement)

Name in full of concerning family member __________________________________________________________________

Birth date _______________________________________________________________________________________________
What is the relationship with insured? ______________________________________________________________________
Total amount of the flight costs? ___________________________________________________________________________
(Please enclose all the original flight tickets and original invoices)

Declaration
Insured declares that he/she has filled in the claim form as best to knowledge and truthfully without withholding any
information that could have influence on the claim. Providing false information or deliberate cause of damage will
exclude all coverage from this insurance.

Place

Date

Signature

Return Address
Please send this original completely filled in form to:
Aon Hewitt, Expatriate Services, P.O. Box 1005, 3000 BA Rotterdam, The Netherlands

6634_UK

leaving valuable goods behind unsupervised or in a car.

On exceeding the amount of the deductible applying to your policy, your medical
expenses claim may be submitted to the company together with the original bills.

of the liability insurance.

We strongly advise you to read the terms and conditions prior to submitting

a claim. In this way unnecessary disappointment can be avoided.

Register of trade Amsterdam 33120658

forfeited in the event of negligent action. This includes, among other things,

compensation may be ensuing for the company is required under the terms

We particularly emphasize the fact that all right to compensation will be

An obligation to report any circumstances from which an obligation to pay

ownership and the value of your property.

manifestation of the loss. This does not apply to ordinary medical expenses.

Save all sales receipts as far as possible of your purchases, proving your

All notices of loss are to be submitted within five days of the occurrence or

Particular note should be taken of the following

Extra costs (air travel)

Accident insurance

Liability insurance

Travel/baggage insurance

Household contents insurance

Medical expenses insurance

Claim instruction

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