Personal Accident insurance – Notification of claim

Please complete this Insurance Claim Form (the “Form”) in full (including signatures and dates wherever requested) and attach all available supporting documentation in order to best adjudicate your claim. Failure to provide truthful and accurate information may result in consequences described in the Declaration below.
The list of initial supporting documentation is attached for your reference, although the Insurer reserves the right to request such other documentation / information as may be necessary to adjudicate the claim.
Handling this claim requires processing of Personal Data (including Sensitive Personal Data e.g. health related) of the Insured Person and of the claimant (if other than the Insured Person). It is important that you are well informed about processing of your Personal Data, therefore, please read the Privacy Notice / Privacy Policy of your Insurer carefully before filling out this Form.
The Insurer and dhig GmbH, acting on behalf of the Insurer, require your explicit consent to process Personal Data included in this Form and related thereto. Furthermore, your authorization for obtaining Personal Data of the deceased Insured Person in question is necessary. The forms of said consent and authorization are attached hereto. Should you decide not to provide requested consent / authorization, the Insurer will not be able to process your claim. 
A parent or legal guardian should complete this Form for a natural person under 18 years old.

The Privacy Notice / Privacy Policy

• The Insurance Policy means the Insurance Policy you are covered under
• The Policyholder means the entity, which arranged your insurance cover and which is indicated in the Insurance Policy as the Policyholder;
• The Insurer means your insurer under the Insurance Policy.

Your explicit consent is required for us to be able to collect, store and use your Sensitive Personal Data for assessing and handling your filed Form and related claims.  Sensitive Personal Data means Personal Data that can reveal a data subject’s racial or ethnic origin, political opinions, religious or philosophical beliefs or trade union membership; it also refers to the processing of data concerning data subject’s health, sexual orientation or sex life.

Please note that:

• you are not obliged to provide this consent,
• you are entitled to withdraw any your provided consent for processing of your Personal Data (including Sensitive Personal Data) at any time as foreseen in the Privacy Documentation.

However, if you do not provide your explicit consent for processing of your Sensitive Personal Data or withdraw it, the Insurer will not be able to assess and handle the Form and your related claim.

I hereby declare and certify the following in respect of this Insurance Claim Form:

– I have filled out the Form fully, truthfully and accurately.

– The Form does not contain any false, misleading or incomplete information.

– I understand that any mistakes, exaggerations, inaccuracies, frauds or other defects in submitting the Form may result in a refusal to pay it, as well as in my obligation to return payments already received from the Insurer.

– I understand that a person who knowingly and with the intent to defraud an insurance company or other person, files an application for insurance or a claim with false information or conceals information for the purpose of misleading, may be guilty of committing a fraudulent insurance act.