Formulare Dauna Asigurare Calatorie in Strainatate

8/14/2019 Formulare Dauna Asigurare Calatorie in Strainatate

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NOTIFICARE DAUNEFECTE PERSONALE / BANIPERSONAL EFFECTS / MONEY CLAIM FORM

Vmulumim pentru notificarea daunei. Vrugm scompletaiacest formular i s-l transmitei ctre:Thank you for notifying us of you claim. Please complete this claim

form and return it to:SPECIALTY CLAIMS SERVICES

PO BOX 51541

LONDON

SE1 0XU

Dacavei nevoie de ajutor pentru completare, vrugmcontactai-ne la:If you need any help in completing this form, please contact us on:

+44 (0)20 7902 7410

Detaliile pgubituluiClaimant details

FormulAdresare

/ Title

Numele complet / Full Name Data naterii /Date of birth

Ocupaie /Occupation

ara de domiciliu / UsusalCountry of Domicile

Adresa pgubitului (claimant address):

Cod potal (postcode):

Telefon (telephone): E-mail:(adresa de email poate fi utilizatpentru corespondendaceste menionat/ e-mail may be used for correspondence if stated)

Detaliile AsigurriiInsurance details

Numr certificat (Certificate number):

Compania de Asigurare (Insurance Company):

Adresa brokerului (Address of Broker):


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Detaliile cltorieiTravel Details

Destinaie (travel destination): ara (country):

Staiune (resort):

Hotel (hotel):

Data plecrii (departure date): / / Data revenirii (return date): / /

Scopul Cltoriei (purpose of trip): Afaceri (Business) Recreere (Pleasure)

Detaliile daunei

Claim details

Data incidentului (date of incident): / / Daunpentru (claim for): Pierderi (loss)

Ora incidentului (time of incident): : AM PM Pagube (damage)Locaia incidentului (place of incident): Amnare (delay)Circumstanele producerii daunei (full circumstances surrounding the claim):

Data la care a ajuns bagajul dvs.daceste o daunpentru ntrzierea bagajelor: / /(the date on which your luggage arrived if claiming for baggage delay)

A fost incidentul raportat Poliiei, Turoperatorului sau Hotelului? DA (YES) NU (NO)(has the incident been reported to the Police, Holiday Rep or Hotel?)

A fost incidentul raportat companiei aeriene implicate? DA (YES) NU (NO)(has the incident been reported to the relevant airline?)

Dacai bifat nu la intrebrile de mai sus, vrugm motivai (if noto any of the above, please state reason why):

Ai mai raportat alte daune pentru bunurile personale, anterior acestei daune? DA (YES) NU (NO)(have you made any personal property claims prior to this claim?)

Dacda, vrugm detaliai (if yes, please give details):

Deinei o asigurare de locuintoate riscurile/bunuri? DA (YES) NU (NO)

(do you hold any household all risk/contents insurance?)



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Deinei asigurare de cltorie asociatcontului dvs. bancar? DA (YES) NU (NO)(do you hold any travel insurance with your current bank account?)


V-ai folosit cardul de credit pentru a achita total sau parial cltoria? DA (YES) NU (NO)(did you use your credit card to pay for all or part of your trip?)

Dacda, vrugm sne transmitei extrasul de cont aferent acestei tranzacii.(if yes, please provide the relevant card statement showing the transaction).

Ai depus o cerere de despgubire la orice alt asigurtor / instituie? DA (YES) NU (NO)(have you submitted a claim to any other insurer / authority?)


Dacdauna dumneavoastrva fi acceptat, vrugm smenionai ctre cine va trebui pltitdespgubirea:(if your claim is agreed, please state to whom settlement should be made):

Numele Beneficiaruluimajuscule: Valuta preferat:(print payee name) (preferred currency)

DeclaraieDeclaration

n deplincunotinde cauz, declar ctoate detaliile furnizate n acest formular sunt adevrate i corecte. n cazul ncare o terparte este rspunztoare pentru pierderile/pagubele produse, toate drepturile n aceastprivinsuntsubrogate Serviciului Daune pentru soluionarea daunei. Dacexistacoperire furnizatprin altpoli, mi dau acordulpentru stabilirea contribuiei de ctre asigurtori. Sunt contient cunele informaii furnizate de mine vor fi puse ladispoziia altor asigurtori pentru a fi folosite la subscriere sau la gestionarea daunelor.

I declare that to the best of my knowledge all particulars contained in this form are true and correct. In the event of a

third party being liable for loss/damage all rights in this matter are subrogated to Specialty Claims Service on settlement

of the claim. If cover exists under any other policy, I give my authority for contribution to be sought from their insurers. I

understand that some of the information provided will be made available to other insurers for underwriting or claims

handling purposes.

Semntura: Data: / /(signed) (date)


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Detaliile obiectelor n daunDetails of Items being claimed

Descrierea completa obiectelordeclarate n daun(full description of

the item being

claimed)

Magazinul ilocaia de undeau fostachiziionate(shop/store and

location where

purchased)

Data / anulachiziionrii(date/year

of purchase)

Dovadaproprietiiataat?(Evidence of

Ownership

enclosed?)

Iniialeleproprietarilor(initials of

Owners)

Preul iniialpltit(original price

paid)

Suma cerutinclusivmoneda(amount

claimed

including

currency)

PENTRUUZULBIROULUIDE DAUNE(OFFICE

USE ONLY)


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InstruciuniGuidance Notes

Urmtoarele documente sunt necesare pentru a putea procesa cererea dvs.(the following documentation must be provided in order for your claim to be processed)

Document Ataat

(item) (enclosed)

Factura originalde rezervare care v-a fost trimisla momentul rezervrii cltoriei (your original booking invoice which is sent to you at the time of booking your trip)

Aceasta confirmdatele de nceput i sfrit ale cltoriei(this confirms your outward and return travel dates)

Polia de asigurare a cltoriei original, cu perioada acoperiti prima pltit (your original travel insurance schedule showing the dates of cover and premium paid)

Dacavei o polianual, atunci va fi acceptato copie a acesteia(if you have an annual policy then a fotocopy will be accepted)

Pentru daunele privind furtul/pierderile(in respect of loss/theftclaims)

Raportul ctre Poliie/Turoperator/Hotel (police/holiday rep/hotel report)

Raport Neregulariti Bagajefurnizat de compania aerian, daceste cazul (Property Irregularity Report given to you by the airline, if applicable)

Vrugm anexai cel puin unul din urmtoarele documente pt fiecare obiect n daun:(please include at least one of the following for each item claimed)

Chitane / Bonuri (purchase receipts)

Extras de cont/card ce demonstreazachiziionarea/retragerea banilor necesari (bank/card statements showing purchases/withdrawals)

Manuale de utilizare, Certificate de garanie / conformitate (user manuals, warranty and/or guarantee slips)

Evalurile emise anterior datei incidentului

(valuations issued prior to the date of loss)Fotografii ale dvs cu bunurile solicitate (photographs of you with the items being claimed)

Chitanele pentru schimburile valutare (banii personali) (currency conversion slips personal money)


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Pentru daunele privind obiectele deteriorate(in respect of damagedarticles being claimed)


Deviz estimativ reparaii sau confirmarea creparaia este imposibil (estimate of repair or confirmation that items are damaged beyond repair)

orice tarif implicat este responsabilitatea asiguratului(Any charge is the responsibility of the claimant)

Vrugm anexai cel putin unul din urmtoarele documente pt fiecare obiect n daun:

(please include at least one of the following for each item claimed)

Chitane / Bonuri (purchase receipts)

Extras de cont/card ce demonstreazachiziionarea/retragerea banilor necesari (bank/card statements showing purchases/withdrawals)

Manuale de utilizare, Certificate de garanie / conformitate (user manuals, warranty and/or guarantee slips)

n cazul bagajelor ntarziate(In respect of baggage delayclaims)

Chitanele obiectelor adiionale achiziionate ca urmare a ntrzierii (receipts for the additional items purchased as a result of the delay)


Confirmarea primitde la compania aeriancu privire la perioada ntrzierii (confirmation from the airline of the length of the delay)

Asigurarea bunurilor din locuinHousehold insurance

Pentru a minimiza efectul solicitrilor frauduloase de daun, Asiguratoriii furnizeazinformaii cu privire la dauneledvs.. Asigurtorii contribuie la soluionarea daunelor altor companii de asigurare. Aceasta distribuie costurile i ajutlameninerea primelor la un nivel redus. Aceste operaiuni se fectueazn concordancu Acordul de Contribuie ABI idacbeneficiai de un bonus pentru lipsa daunelor acesta nu va fi afectat.To minimize the effect of fraudulent claims Insurers share information about your claims. Insurers contribute to the

settlement of each others claims. This shares the costs and helps to keep your premiums down. This is done in

accordance with the ABI Contribution Agreement and if you have a no claims discount this should not be affected.


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NOTIFICARE DAUNPIERDEREA MBARCRII / NTRZIEREA CLTORIEITRAVEL DELAY / MISSED DEPARTURE CLAIM FORM



PO BOX 51541

LONDON

SE1 0XU


+44 (0)20 7902 7410


FormulAdresare

/ Title


Ocupaie /Occupation

ara de domiciliu / UsualCountry of Domicile









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Staiune (resort):

Hotel (hotel):



Detaliile daunei

Claim details

NTRZIEREA CLTORIEITRAVEL DELAY

Motivele ntrzierii (reason for the delay):

Punctul de plecare unde s-a produs ntrzierea :

(departure point where delay occurred)

Punctul de sosire:(arrival point)

Data i ora programate pentru plecare: / / : AM PM(scheduled date and time of departure)

Numrul zborului / navei:(flight / ferry number)

Numrul companiei aeriene / navei:(airline / ferry number)

Data i ora reale ale plecrii: / / : AM PM(actual date and time of departure)

Numrul zborului / navei:(flight / ferry number)

Numrul companiei aeriene / navei:(airline / ferry number)

Numrul de ore de ntrziere:(number of hours delay)

Ai primit orice restituiri / variante alternative de la operatorul cltoriei? DA (YES) NU (NO)

(have you received any refund/alternative booking from the travel operator?)Dacda, vrugm detaliai (if yes, plese give details):


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PIERDEREA MBARCRIIMISSED DEPARTURE

otivele pierderiimbarcrii (reason for the missed departure):

Aeroportul / portul de plecare:(departure Airport/Port for your trip)

Punctul de pierdere a conexiunii:(point of connection failure)

Metoda de transport:(method of transport)

Mijloacele implicate pentru reluarea cltoriei:(means employed to rejoin trip)

Cheltuieli adiionale solicitate ca daun:(additional expenses being claimed)

Ai solicitat despgubiri / ai transmis o plngere, sau ai primit orice restituri de la operator? DA (YES) NU (NO)(have you made a claim/complaint, or received any refund from the operator?)

Dacda, vrugm sne transmitei copia corespondenei.(if yes, please provide a copy of any correspondence)


Numele Beneficiaruluimajuscule: Valuta preferat:(print payee name) (preferred currency)


n deplincunotinde cauz, declar ctoate detaliile furnizate n acest formular sunt adevrate i corecte. n cazul ncare o terparte este rspunztoare pentru pierderile/pagubele produse, toate drepturile n aceastprivinsuntsubrogate Serviciului Daune pentru soluionarea daunei. Dacexistacoperire furnizatprin altpoli, mi dau acordulpentru stabilirea contribuiei de ctre asigurtori. Sunt contient cunele informaii furnizate de mine vor fi puse ladispoziia altor asigurtori pentru a fi folosite la subscriere sau la gestionarea daunelor.I declare that to the best of my knowledge all particulars contained in this form are true and correct. In the event of a




handling purposes.



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Document Ataat(item) (enclosed)




Pentru daunele privind ntrzierea cltoriei:(in respect of travel delayclaims)

Confirmarea de ctre operator a motivelor exacte, ora i durata ntrzierii (confirmation from the operator of the exact reason, time, and length of delay)

Pentru daunele privind pierderea mbarcrii:(in respect of missed departureclaims)

Confirmarea de ctre autoritatea ndreptaitreferitoare la motivele implicate [de exemplu: raport defeciuni, raport trafic, confirmare ntrziere companie aerian/ nav](confirmation from the appropriate authority confirming reason for missed departure;

i.e.: breakdown report, traffic report, airline/ferry delay confirmation)

Chitanele transportului alternativ i/sau cazrii pentru costurile suplimentare solicitate (receipts for the additional travel and/or accommodation costs being claimed)

Dovada restituirilor efectuate de operator / compania aerian (evidence of refund from tour operator / airline)

Dacai cerut despgubiri i unei alte instituii, copia corespondenei (if you have submitted a claim to another authority, copies of all correspondence)


11/22

NOTIFICARE DAUNANULAREA CLTORIEI / PIERDEREA AVANSULUICANCELLATION / LOSS OF DEPOSIT CLAIM FORM



PO BOX 51541

LONDON

SE1 0XU


+44 (0)20 7902 7410


FormulAdresare

/ Title


Ocupaie /Occupation










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Staiune (resort):

Hotel (hotel):



Detaliile daunei

Claim details

Motivele anulrii:(reason for the cancellation)

Dacmotivele anulrii sunt unele medicale, certificatele medicale ataate vor trebui completate de ctre doctorulcurant al persoanei a crei condiie a cauzat anularea cltoriei.(if the reason for cancellation is medically related, the attached medical certificates must be completed by the usual

doctor of the person whose condition caused the cancellation of the trip)

Dacanularea a fost determinatde o persoancare nu cltorea i care nu este asiguratprin polia dvs., vrugmmenionai relaia dvs. cu acea persoan:(if the cancellation has been caused by a person not travelling and not insured on your policy, please state the

relashionship of that person to you)

Data la care ai achiziionat/rennoit polia: / /(date your insurance policy was purchased or renewed)

Perioada de acoperire menionatn poli: / / la / /(period of cover as stated on your travel insurance schedule) (to)

Data la care ai rezervat cltoria: / / Data la care ai anulat cltoria: / /

(date you booked your trip) (date you cancelled your trip)

Total avans pltit: $ Data pltii: / /(total deposit paid) (date paid)

Total rmas pltit: $ Data pltii: / /(total balance paid) (date paid)

Total sumreturnat: $ Data returnrii: / /(total amount refunded) (date refunded)

Suma TotalSolicitatca Daun: $(total amount claimed)


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Ai solicitat i alte daune pentru anulri anterioare acestei daune? DA (YES) NU (NO)(have you made any cancellation claims prior to this claim?)


Deinei asigurare de cltorie asociatcontului dvs. bancar? DA (YES) NU (NO)(do you hold any travel insurance with your current bank account?)


Deineti asigurare de cltorie asociatturoperatorului respectiv? DA (YES) NU (NO)(do you hold any travel insurance with the relevant tour operator?)


V-ai folosit cardul de credit pentru a achita total sau parial cltoria? DA (YES) NU (NO)(did you use your credit card to pay for all or part of your trip?)

Dacda, vrugm sne transmitei extrasul de cont aferent acestei tranzacii.(if yes, please provide the relevant card statement showing the transaction).

Ai depus o cerere de despgubire la orice alt asigurtor / instituie? DA (YES) NU (NO)(have you submitted a claim to any other insurer / authority?)



Numele Beneficiarului majuscule: Valuta preferat:(print payee name) (preferred currency)


n deplincunotinde cauz, declar ctoate detaliile furnizate n acest formular sunt adevrate i corecte. n cazul ncare o terparte este rspunztoare pentru pierderile/pagubele produse, toate drepturile n aceastprivinsuntsubrogate Serviciului Daune pentru soluionarea daunei. Dacexistacoperire furnizatprin altpoli, mi dau acordulpentru stabilirea contribuiei de ctre asigurtori. Sunt contient cunele informaii furnizate de mine vor fi puse ladispoziia altor asigurtori pentru a fi folosite la subscriere sau la gestionarea daunelor.I declare that to the best of my knowledge all particulars contained in this form are true and correct. In the event of a




handling purposes.



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Document Ataat

(item) (enclosed)


Dacai fcut rezervri individuale (de exemplu: nchiriat maina, hotelul aeroportului)vrugm sne furnizai facturile pentru fiecare dintre acestea

(if you have booked independent arrangements i.e. car hire, airport hotel

then please provide us with a booking invoice for each item being claimed)

Factura originalde anulare care v-a fost trimisla momentul anulrii cltoriei (your original cancellation invoice which is sent to you at the time of cancelling your trip)

Dacai fcut rezervri individuale (de exemplu: nchiriat maina, hotelul aeroportului)vrugm sne furnizai facturile de anulare pentru fiecare dintre acestea

(if you have booked independent arrangements i.e. car hire, airport hotel

then please provide us with a cancellation invoice for each item being claimed)



Dovezile necisitii de a anula cltoria: (evidence of necessity to cancel your trip)

- Medicale certficatul ataat (medical the attached medical certificate)- Ciclicitate informarea de ciclicitate confirmnd eligibilitatea pentru un astfel de pachet

(redundancy redundancy notice confirming eligibility for redundancy package)

- Solicitarea prezenei n instanCitaie (Court Attendance Court Subpoena)Dovada restituirilor efectuate de operator / compania aerian

(evidence of refund from tour operator / airline)Dacai rezervat curse de linie, toate taxele de aeroport trebuie solicitate companiei aeriene.(if you have booked scheduled flights, all air taxes must be claimed from the airline)

Dacai cerut despgubiri i unui alt asigurator, copia corespondenei (if you have submitted a claim to another insurer, copies of all correspondence)


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NOTIFICARE DAUNCHELTUIELI MEDICALENTRERUPEREA CLTORIEIMEDICAL EXPENSES / CURTAILMENT CLAIM FORM



PO BOX 51541LONDONSE1 0XU


+44 (0)20 7902 7410


FormulAdresare

/ Title


Ocupaie /Occupation










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Staiune (resort):

Hotel (hotel):



Detaliile dauneiClaim details

Data, ora i locul producerii bolii/vtmrii: / / : AM PM(date, time and place of illness/injury)

Boala sau rnirile suferite (illness suffered or injuries sustained):

Pentru vtmri, vrugm detaliai circumstanele incidentului (if injury, please provide full circumstances of theincident):

Ai suferit de o boalasemntoare n trecut? . DA (YES) NU (NO)

(have you suffered from a similar condition before?)Dacda, rugai doctorul curant scompleteze certificatul medical ataat.(if yes, please ask your normal doctor to complete the medical certificate attached)

Ai prezentat EHIC (card European de asigurri de sntate)?

(numai pentru rile membre UE) DA (YES) NU (NO)(did you present your EHIC? EU countries only)

Dacda, vrugm completai exonerarea de rspundere ataat.(if yes, please complete the disclaimer attached)

Ai contactat serviciile medicale de urgen? DA (YES) NU (NO)

(did you contact the Emrgency Medical Assistance Company?)Dacda, indicai numrul de referinfurnizat:

(if yes, please provide the reference number given to you)


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Ai fost internat? Dacda, indicai:(were you hospitalized as an in-patient? If so, please provide):

Data internrii (date admitted): / / Data externrii (date discharged): / /Ora Internrii (time admitted): : AM PM Ora Externrii (time discharged): : AM PM

Daceste cazul, perioada cazrii extinse: / / pn: / /(if applicable, period of extended accommodation) (to)

V-ai ntors acasmai devreme? DA (YES) NU (NO)(did you return home early?)

Dacda, specificai data revenirii: / /(if yes, please provide the date on which you returned)

Deinei orice altasigurare care acoperacest tip de daun? DA (YES) NU (NO)(Do you hold any other insurance that may cover this loss?)

Exemplu: Asigurri de Sntate, asigurri asociate contului bancar, operatorului de turism, cardului de credit(I.E: Private Health, Bank Account, Credit Card, Tour Operator)

Dacda, furnizai detalii:(if yes, please give details)


Numele Beneficiarului majuscule: Valuta preferat:(print payee name) (preferred currency)


n deplincunotinde cauz, declar ctoate detaliile furnizate n acest formular sunt adevrate i corecte. n cazul ncare o terparte este rspunztoare pentru pierderile/pagubele produse, toate drepturile n aceastprivinsuntsubrogate Serviciului Daune pentru soluionarea daunei. Dacexistacoperire furnizatprin altpoli, mi dau acordul

pentru stabilirea contribuiei de ctre asigurtori. Sunt contient cunele informaii furnizate de mine vor fi puse ladispoziia altor asigurtori pentru a fi folosite la subscriere sau la gestionarea daunelor.I declare that to the best of my knowledge all particulars contained in this form are true and correct. In the event of a




handling purposes.



18/22


Detaliile cheltuielilor solicitateDetails of expenses being claimed

Data cheltuielii(date of

expense)

Detalii(details of expense)

Suma solicitat(claimed amount)

ChitanAtaat?(receipt attached?)

Pltit / nepltit?(paid / unpaid?)

PENTRU UZULBIROULUI

(OFFICE USE ONLY)



Document Ataat(item) (enclosed)




Dovezile ce susin dauna dvs: (evidence to support your claim)

- Chitane originale / facturi pentru cheltuielile solicitate(original receipts/invoices for expenses being claimed)

- Rapoartele/nregistrrile doctorului/spitalului(hospital/doctor reports/records)

Dacv-ai ntors mai devreme acas: (if you returned home early)

Confirmarea doctorului curant referitoare la necesitatea ntoarcerii anticipate acas,sau dacntoarcerea a fost rezultatul unei boli/mori a unei rude, solicitm completarea

certificatului ataat de ctre doctorul curant al persoanei care a cauzat ntreruperea cltoriei(confirmation from the treating doctor of the medical necessity to return early, or if the return

was a result of an illness/death of a relative we require the medical certificate attached to be

completed by the usual doctor of the person causing curtailment)


19/22


Pentru cheltuieli medicale efectuate numai pe teritoriul UE, vrugm completai exonerarea de rspundere ataat.(for medical expenses incurred in the EU only, please complete the attached disclaimer)

Daccheltuielile au fost rezultatul unui incident: (if the expenses are a result of an incident)

Copiile oricrui raport ntocmit de poliie(copies of any Police reports)

Detaliile companiei de asigurare a terei persoane(details of the third partys insurance company)

Detaliile oricrui avocat numit de dvs. pentru a instrumenta un caz de Vtmare Corporal(details of any solicitor that you may have appointed to handle a Personal Injury Claim)

Dacai cerut despgubiri i unui alt asigurator, copia corespondenei (if you have submitted a claim to another insurer, copies of all correspondence)


20/22


Exonerare de rspundere (numai pentru rile UE)Disclaimer (EU countries only)

Prin prezenta, sunt de acord ca SPECIALTY CLAIMS SERVICE ssolicite rambursarea cheltuielilor medicale efectuate caurmare a tratamentului medical;(I hereby consent to Speciality Claims Services seeking reimbursement of medical expenses paid arising out of medical

treatement).

Primit n (destinaie): de la (data mbolnvirii): / /(received in destination) (from date of illness)

Numele (majuscule):(print name)

Adresa complet:(full address)

Cod potal:(postcode)

Data naterii: / / Naionalitate:(date of birth) (nationality)

CNP:(NI number)

Semnatura Data / /(signed) (date)

Daccheltuielile medicale se referla copilul dvs, menionai:

(if medical expenses relate to your child, please confirm)

Numele complet al copilului:(full name of child)

Data naterii: / / Naionalitatea:(date of birth) (nationality)

Data plecrii n strintate: / /(date of departure abroad):


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CERTIFICAT MEDICAL

MEDICAL CERTIFICATE

A se completa de ctre Medicul de Famile al persoanei ce determinanularea cltoriei (indiferent dacparticipa sau nu la

cltorie). Orice tarif solicitat pentru completarea acestui document este responsabilitatea Persoanei Asigurate i nu va fi restituit de

ctre Asiguratori.

(to be completed by the general practitioner of the person causing cancellation (whether travelling or not). Any charge made for the

completion of this document is the responsibility of the insured person and is not refundable by the insurers).

NOTA: pentru a evita ntrzierile i corespondena inutil, vrugm scompletai acest formular cu MAJUSCULE i srspundei ct

mai cuprinztor la toate ntrebrile (to avoid delay and unnecessary correspondence please complete this form in BLOCK CAPITALS

and answer each question as fully as possible)

1. Numele complet al persoanei ale crei date medicale suntcompletate (full name of the person to whom these medical details

apply)

2. Data naterii i Vrsta (date of birth and Age) Data: / / Varsta (age):3. Suntei medicul de familie al doamnei/domnului? Dacnu, n ce

calitate suntei implicat? (are you his/her usual general

practitioner? If not, in what capacity are you involved?)

DA (YES) NU (NO)

4. Vrugm menionai natura exacta bolii/accidentului care adeterminat anularea (please state the exact nature of

illness/accident which made cancellation necessary)

5. Existun istoric medical precedent al bolii de mai sus sau alte bolirelevante? DacDA, furnizai detalii (is there any previous medical

history of the above condition or other relevant condition? If YES,

please give details)

DA (YES) NU (NO)

6. Referitor la aceastboala, cnd a fost consultat prima oarpacientul? (when did the pacient first consult you with regard to

this condition?)

Data: / /

7. Cnd a fost diagnosticatboala? (when was the conditiondiagnosed?)

Data: / /

8. Cnd a devenit necesaranularea cltoriei? (when wascancellation deemed necessary?)

Data: / /

9. Cunoteai planurile de cltorie cnd ai fost consultat primaoar? DacNU, vrugm confirmai prima datla care anularea

cltoriei ar fi putut fi anticipat. (were you aware of the travel

plans when first consulted? If NO, please confirm the first date pon

which cancellation could have been anticipated)

DA (YES) NU (NO)

Data: / /

10. Menionai dacla momentul rezervrii cltoriei (at the time thetrip was booked, please state whether):a) Boala era sub control (The condition was under control)b) Aceasta este o agravare a unei boli existente, i dacda data

agravrii (This was an exacerbation of any existing condition

and if so the date of exacerbation)

c) Pacientul era pe lista de ateptare pentru internare sau eradj internat (The patient was either on a waiting list for in-

patient treatment or was an in-patient)

d) Pacientul primise un diagnostic terminal (The patient hadreceived a terminal prognosis)

e) Dacpacientul cltorea, boala era o contraindicaie pentrucltorie (If the patient was one of those travelling, the

condition was a contraindication to do so)

f) Cltoria a fost efectuatn pofida sfaturilor medicale? (Wastravelling contrary to medical advice?)

DA (YES) NU (NO)

DA (YES) NU (NO) Data: / /



DA (YES) NU (NO)

DA (YES) NU (NO)


22/22

CERTIFICAT MEDICAL

MEDICAL CERTIFICATE

11. Doar n caz de sarcin(pregnancy only)a) Data ultimei menstruaii (date of LMP)b)

Data confirmrii sarcinii (date pregnancy confirmed)

c) Data estimata naterii (estimated date of confinement)d) Condiiile medicale exacte ce mpiedicau calatoria (exact

medical condition preventing travel)

Data: / /

Data: / /Data: / /

Certific canularea cltoriei s-a datorat numai condiiilor medicale menionate.

(I certify that cancellation was due solely to the medical conditions stated)

Numele i semnatura:

(name and signature)

Calificri:

(qualifications)

Telefon:

(telephone number)

tampila

(practice stamp)

Formulare Dauna Asigurare Calatorie in Strainatate

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Transcript of Formulare Dauna Asigurare Calatorie in Strainatate