Trip Cancellation – Claim Form
The following must always be enclosed:
• Original travel certificates/flight tickets
• Documentation of trip cancellation and information on any refund
• Statement showing that the trip has been paid via credit card/a business travel account (if required to be eligible for cover)
• If’s medical certificate, see page 3, must be completed by the usual doctor of the person whose medical condition
gives rise to the claim.
Please remember to enclose documentation of the claim:
• In the event of bereavement a copy of the death certificate must be enclosed.
• In the event of other claims original documentation must be enclosed.
Please remember to itemise your claim for compensation, for instance: “Flight tickets DKK 4,000 and hotel EUR 450”.
Important
Failure to submit all the necessary information and documentation will delay the handling of your claim because it will
be necessary to ask you further questions and to await the receipt of documentation.
If you are insured via your credit card
Bank:_ ______________________________________ Type and name of credit card: ___________________________________
If you have business travel insurance with If
Policy number: _________________________________________________
Policyholder
Name: _____________________________________________________________ CPR No: ______________________________
Address: ___________________________________________________________ Postal code/town: ______________________
Tel: _________________ Cell phone: _____________ Email: ________________________________________________________
Person suffering from an illness/injury
Name: ______________________________________________________________ CPR No: ______________________________
Address: ____________________________________________________________ Postal code/town: _____________________
Trip details
Purpose
Holiday
Business
Holiday and business
Other: ___________________________________________
Date of booking: _____________________________ Destination/country:____________________________________________
Date of departure: ____________________________ Date of return: _________________________________________________
Has the trip been cancelled?
Yes
No
If yes, state date: _______________________________________________
Price of trip excl cancellation insurance (DKK): _________________________________________________________________
Have you received a refund from the tour operator?
Yes
No
If yes, state amount in DKK: ___________________ Amount claimed in DKK: ________________________________________
Claim details
Date of incident giving rise to the cancellation: _________________________________________________________________
Reason for cancellation/diagnosis:____________________________________________________________________________
Bank: _______________________________________ Reg. No: _________________ Account No: _ _______________________
SWIFT/BIC: _ ________________________________ IBAN: ________________________________________________________
8367.0410
Bank details/NemKonto Easy Account
Compensation, if any, CANNOT be transferred to a credit card but will be credited to your bank account.
Claim Form
Medical information
Name of the usual doctor of the person suffering from an illness/injury: ____________________________________________
Address: ____________________________________________________________ Postal code/town: _ ____________________
CPR No: ___________________________________________________________________________________________________
Persons travelling with the insured
How is/was the person suffering from an illness/injury related to the policyholder?
Spouse/cohabiting partner
Parent/parent-in-law _
Child/child-in-law/grandchild
Brother-in-law/sister-in-law Grandparent
Brother/sister
_
Please state all persons who have cancelled the same trip:
Name CPR No Travelling companion
Relationship to policyholder ________________________________________ ___________________________ _ _____________________________________
________________________________________ ___________________________ _ _____________________________________
________________________________________ ___________________________ _ _____________________________________
________________________________________ ___________________________ _ _____________________________________
________________________________________ ___________________________ _ _____________________________________
________________________________________ ___________________________ _ _____________________________________
________________________________________ ___________________________ _ _____________________________________
Other insurance/credit cards
Do you have other cancellation insurance?
Yes
No
If yes, state company and policy number: _______________________________ Notified?
Yes
No
Do you have cancellation insurance which is provided with a credit card (eg MasterCard, Eurocard, Diners etc)?
Type of credit card: ___________________________________________________ Card number: _ ________________________
Type of credit card: ___________________________________________________ Card number: _ ________________________
Signature
By submitting this claim, I certify that all answers to the questions above are true. I confirm that I am aware that any
untruthful statements may result in no or reduced compensation. I consent to If obtaining information from therapists,
places of treatment, dentists, doctors, hospitals and other relevant institutions such as insurance companies, the police,
public authorities and the National Board of Industrial Injuries in Denmark who know of or will know of the claim and/or
my state of health. In addition If may inform such individuals of the information disclosed.
Signature of policyholder: _____________________________________________ Date: _________________________________
To be submitted together with the medical certificate and the consent form to:
If, Stamholmen 159, 2650 Hvidovre, Denmark, tel +45 7012 2424, www.if.dk
Medical Certificate
To the patient’s usual doctor
If needs to determine whether there is a causal connection between the illness/injury and that which occasioned the
illness/injury as well as whether any pre-existing illnesses/injuries may be related to the illness/injury suffered and the
patient’s symptoms. Consequently it is important that If is informed of all symptoms and conditions that may have a
bearing on the assessment.
Please complete
Name of patient: _____________________________________________________________ CPR No: _ ____________________
Date of departure: __________________________________________________________________________________________
To be completed by the patient’s usual doctor
Nature of illness/injury. Please state the exact diagnosis in English and Latin
English: _________________________________________________________ Latin: ____________________________________
When did the patient contract this illness/sustain this injury?
Date: ___________________________________________________________ Place: ____________________________________
Date and place of first consultation regarding the illness/injury in question
Date: ___________________________________________________________ Place: ____________________________________
When did you start diagnosis relating to the patient’s symptoms/condition? Date of first symptoms
Date: ___________________________________________________________ Date: _ ___________________________________
Relevant only in case of travel
In your opinion, does the illness/injury/general health of the patient prevent him/her from travelling?
Yes
No
If yes, why? ________________________________________________________________________
Has the patient previously suffered from the same illness/injury/symptoms?
Yes
No
If yes, when? _______________________________________________________________________
In case of chronic illness
Has the condition of the patient deteriorated suddenly and unexpectedly?
Yes
No
If yes, when? _______________________________________________________________________
Has the patient been referred to a specialist/hospital?
Yes
No
If yes, when? _______________________________________________________________________
Remarks (special circumstances that should be considered in relation to the case)
__________________________________________________________________________________________________________
Signature
This Medical Certificate has been completed by me in accordance with my records, my knowledge of the patient, my
questions to the patient and my examination.
Signature of doctor: _____________________________________________________ Date: _ ____________________________
Stamp: _____________________________________________ Doctor’s CPR No/CVR No: _____________________________
Consent for access to health data etc
Reason for consent
Under the Danish Insurance Contracts Act you are obliged to disclose all available and relevant information when you
claim compensation from your insurance company. Consequently you are obliged to provide If with all information that
may have a bearing on the assessment of your case and the size of the insurance benefit.
Insurance payout
According to the Danish Insurance Contracts Act you are not entitled to receive any benefit under the insurance policy
until 14 days after If has received the information necessary to assess your case and determine the size of the insurance payout.
Your doctor may pass on health data etc
With your consent your doctor may pass on information regarding your state of health, information regarding other personal matters as well as other confidential information. This follows from the provisions of the Danish Health Act.
You can revoke your consent at any time
Your consent is valid for one year. A copy of your consent will be given to everyone from whom If wishes to obtain
health data etc. You can revoke your consent at any time.
You be will notified whenever If obtains information
Each time If obtains health data etc you will be notified of why the information is required, the nature of the information
required, for which exact period information is required and from whom If wishes to collect information.
Consent
By my signature I certify that all answers to the questions above are true. I confirm that I am aware that any untruthful
statements may result in no or reduced compensation. I consent to If obtaining information from therapists, places of
treatment, dentists, doctors, hospitals and other relevant institutions such as insurance companies, the police, public
authorities and the National Board of Industrial Injuries in Denmark who know of or will know of the claim and/or my
state of health. In addition If may inform such individuals of the information disclosed.
Name: ________________________________________________________________ CPR No:____________________________
Signature: _____________________________________________________________ Date: _______________________________
The certificate committee of the Danish Medical Association has approved that this consent form be used to obtain
health data from medical practitioners.
Information is obtained by means of an agreed form which is supplemented by a copy of or extract of the relevant
medical file if so requested by the insurance company.
The Danish Medical Association and the Danish Insurance Association 2008