Insurance no.

Please send your documents toHanseMerkur Reiseversicherung AGAbt. RLK
Postfach20352 Hamburg

Health Insurance information on an insured event for foreign visitors
Please complete all fields accurately and legibly. Please note that failure to provide correct or complete
information may render your insurance cover invalid (for more on this, read the last Section).
GeneralPlease attach proof of insurance and proof of the premium payment.
Details on the claimant and the trip:
Family name, first name :Date of birth:

Nationality (nationalities):
Occupation/work performed at the date of the illness or injury:
Employer at the date of the illness or injury:
Street and house number:
Postal code/Town:

Country:

Email/fax:

Phone (private with code):

Mobile phone:

Phone (work with code):

Details on benefits be paid:
Account holder:
Name and place of bank:
Bank sort code/BIC/SWIFT/branch code:
Account/IBAN no.:Details on your entry:
Date of your entry into the EU/Germany:
Please attach a copy of your bus, rail, plane tickets, your reservation confirmation or the stamp of arrival/departure in your passport.

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HanseMerkur Reiseversicherung AG
Siegfried-Wedells-Platz 1, 20354 Hamburgwww.hmrv.deInsurance no.

Health Insurance - information on an insured event for foreign visitors

Which country were you treated in?
When will you return to your native country? Date:
Details on the insured event:Please submit originals of doctors' bills, prescriptions and receipts. If payment has already been made, e.g. by your statutory
health insurer, it is sufficient to submit a copy with a note of the reimbursement. In the case of in-patient treatment, please attach a copy of the discharge report.

In the case of illness or accident:a) What was the illness for which you had treatment? Please describe the diagnosis in your own words.

b) When did the complaints first arise? Please name the date:
Has the treatment taken place as a result of a vaccination or preventive medical check-up?
check-upvaccination

In the case of dental treatment:a) Did you have toothache?

YesNob) Did you get dentures, crowns, onlays, etc.?

YesNoc) If yes, where?

Upper right

Lower rightUpper left

Lower leftd) When did the complaints first arise? Date:
In the case of treatment due to pregnancy:a) When was the pregnancy determined?
b) In which week of pregnancy was the pregnancy determined?
Please attach a complete copy of the pregnancy medical records.
c) Why were you treated during the pregnancy?
check-upcomplaints/early labour

premature birthdeliveryd) In case of complaints during pregnancy:
When did the complaints first arise? Date:
In the case of death:
Please provide details of the date and cause of death. Please attach a copy of the death certificate.

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HanseMerkur Reiseversicherung AG
Siegfried-Wedells-Platz 1, 20354 Hamburgwww.hmrv.deHealth Insurance - information on an insured event for foreign visitors

Insurance no.

More details on the insured event:a) When did you first receive medical treatment? Date:b) Please name all the doctors who treated you during your stay abroad (name, address, telephone number,
fax number, email address). If there is insufficient space, please attach a separate sheet.

c) Had you already received medical treatment for the illness before the startof the journey?

YesNod) Was the treatment the consequence of an illness or accident treated
before the start of the journey?

Yes

NoIf yes, please give us details of the doctors providing treatment (date, name, address, telephone number)e) Who is or was your family doctor/dentist/specialist doctor in the last 12 months before the start of thejourney? Please give us details of the names and addresses of the doctors, the treatment periods and thediagnoses. If there is insufficient space, please attach a separate sheet.

f) Prior to the start of the journey, did you have complaints or illnesses that werenot treated?

Yes

NoYes

NoIf yes, what were these complaints or illnesses?
Details in the case of accident:a) Place of accident (street, house number, place):b) Date of the accident:

Time of the accident:c) Please describe how the accident happened:d) Was the accident caused by (an)other person(s)?
If yes, please give us name(s) and address(es):

G88 Incoming DE-EN 04.21 PDF A 003388 - 075 - 000290 - 000000000001

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HanseMerkur Reiseversicherung AG
Siegfried-Wedells-Platz 1, 20354 Hamburgwww.hmrv.deHealth Insurance - information on an insured event for foreign visitors

Insurance no.

e) Did the accident happen at your place of work, during work time orat your school during lessons or a school event?

YesNof) Did the accident happen on your way to your place of work/schoolor from work/school to your home?

YesNog) Have the invoices on the accident-related treatment already been submitted to the person
causing the accident or to that person's liability insurer for reimbursement?

Yes

NoYes

No

If yes, to (Name, address, insurance number of the liability insurance):h) Are there witnesses to the accident? Please give names and addresses:i) Which police station dealt with the accident? Please give us details of the police station and reference numberand attach a copy of the police report.

Details on further insurance policies:a) Have you been insured by us in the past?

YesNoYesNo

If yes, when and what was the policy number?

b) Which other insurance company has given you health insurance cover in the last five years?
(name, address, policy number)c) Have the invoice documents submitted to us been submitted to anotherinsurance company?
If yes, please attach a copy of the other insurance company's settlement letter.

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Siegfried-Wedells-Platz 1, 20354 Hamburgwww.hmrv.deHealth Insurance - information on an insured event for foreign visitors

Insurance no.

d) Have you submitted medical invoices for reimbursement to another insurance company
in Germany in the last five years?

Yes

NoIf yes, please give us details of the year, country in which you were treated,
name, address and policy umber of the insurance company:

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HanseMerkur Reiseversicherung AG
Siegfried-Wedells-Platz 1, 20354 Hamburgwww.hmrv.deInsurance no.

Health Insurance - information on an insured event for foreign visitors

Information under Sec. 28 para. 4 VVG
Information on the consequences of breach of duty after the insured event
Dear customer,
once the insured risk has occurred, we require your assistance.
Duties to provide information and assist in clarification
On the basis of the contractual documents entered into with you, we may demand, after the occurrence of the insured risk, that you provide us with all information that is necessary to determine the nature of the insured risk or
the scope of our liability (duty to provide information) and to provide us with all details that serve to clarify thematter (duty of clarification) to enable us to properly assess our liability. However, we may also demand that you
provide us with supporting records/documents provided that such demands are reasonable.
Loss of benefits
If, contrary to the contractual agreements, you wilfully provide no information or incorrect information or wilfully
fail to provide us with the supporting records/documents that we request, you will lose your entitlement to the insurance benefits. If your breach of these obligations is based on gross negligence, you will not fully lose your entitlement, but we may reduce the benefits in proportion to its seriousness. There will be no reduction if you provethat you have not been grossly negligent in infringing the obligations.
Despite a breach of your obligations to provide information or assist in clarification or provide supporting
records/documents, we will still be obliged to pay benefits insofar as you can prove that the wilful or grossly negligent breach was not the caused by the investigation of the insured event or by the investigation of the scope of
our liability.
If you fraudulently breach the obligation to provide information, to clarify matters or to provide supporting
records/documents, we will in all cases be released from our liability to pay benefits.
NoteIf a third party and not you yourself is entitled to the benefits under the contract, such third party must also provide information, assist in clarifying matters and provide supporting records/documents.
Final statements
I confirm that the information I have provided above is true and complete. I am aware that incorrect or incomplete
information may lead to loss of cover. I have taken note of the above information in accordance with Sec. 28 para. 4 of the Insurance Contract Act.
In addition I assign my claims and demands against a party causing the accident/liable party or against my statutory health insurance fund/private health insurer in the amount of the benefits paid by HanseMerkur Reiseversicherung AG to HanseMerkur Reiseversicherung AG.

Place/DateSignature of policyholder

Signature of Insured person(or legal representative)G88 Incoming DE-EN 04.21 PDF A 003388 - 075 - 000290 - 000000000001

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HanseMerkur Reiseversicherung AG
Siegfried-Wedells-Platz 1, 20354 Hamburgwww.hmrv.de