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Insurance claim due to flight delay / cancellation

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Policyholder*

Policy No.*

Validity term of the policy from (dd.mm.yyyy)*

Validity term of the policy to (dd.mm.yyyy)*

Insured person*

Personal identification code*

Address*

Post code*

Phone no.*

Fax no.

E-mail*

Date of flight delay / cancellation (dd.mm.yyyy)*

The flight route and flight, which was delayed / cancelled*

Flight delay / cancellation - case description*

Your expenses due to flight delay / cancellation
(Purchased Items / Purchase price)

Recompense receiver

First name, Last name

Personal identification code

Bank account no.

Attached documents

Max 500 Kb

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Only when a message appears on the screen and a copy of your claim is received in your e-mail box, your claim has been sent successfully.

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With this I undertake to provide all the information at my disposal regarding the mentioned event, as well as co-operate to obtain additional information necessary for reviewing this insurance claim.
If the information regarding the conditions of the event provided by me is delusive or false, or if the orders of the insurer will not be followed, the insurance indemnity will be decreased or rejected.

I certify that the information provided is true*