Report damage request refund

First Name*

Last Name*

E-mail Address*

Phone Number (optional)

Your policy number (Polizzennummer) - (starting with 700.........)

Bank Details:

Please enter your personal European bank account.

The refund will be transferred to this account.

Bank Name*

IBAN Code*

BIC Code*

Text (please very briefly describe what the refund is for)*

Important:

To be able to process the claim you need to upload the diagnosis from the doctor and the actual bill.

In case you did not get a diagnosis please get in touch with your doctor for it!

Upload Files*

Drop files here or

Accepted file types: jpg, pdf, txt, tiff, png, bmp, jpeg, png, Max. file size: 10 MB.

I hereby confirm that I have downloaded, read and accept the Data Protection Policy *

Confirm*

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