Please send your documents toHanseMerkur Reiseversicherung AGAbt. RLK
Postfach20352 Hamburg

Insurance no.

Travel Luggage Claim Form
Dear Policyholder,In order to process your claim efficiently we require specific information from you. Please complete this form as
accurately as possible to avoid any unnecessary queries. Thank you for your cooperation and do not hesitate tocontact us if anything is unclear to you.
Data protection notice: we store your personal data for the purposes of assessing our service obligations. For
further information on data protection and your rights go to https://www.hmrv.de/en/privacy/information orplease request a copy from us.
I.

Particulars of insured individuals affected by the damaging event):Name, address, date of birth,Tel-no. E-Mail, occupation (continue on an extra sheet if nessascary)a)
Insured:

□ no

□ yes

No of suitcases:

No of bags:others:Insured:

□ no

□ yes

No of suitcases:

No of bags:others:Insured:

□ no

□ yes

No of suitcases:

No of bags:others:Insured:

□ no

□ yes

No of suitcases:

No of bags:others:b)

c)d)

II.

Details relating to the policy:

When and where did you take out the travel insurance policy?
Please submit a copy of the policy or proof of premium payment (eg copy of bank statement showing debit ofpremium).

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HanseMerkur Reiseversicherung AG
Siegfried-Wedells-Platz 1, 20354 Hamburgwww.hmrv.deTravel Luggage Claim Form

Insurance no.

III. Details of journey:
1. Intended duration of journey:

Fromto2. Date of commencement (date and time):

Fromto3. Country of destination:
4. Which tour operator organised the journey?
Please send us your booking confirmation (copy)□ The journey was organised by myself (ourselves)
5. How was the journey undertaken□ by air □ by rail □ by car □ by other means

IV. Details of the damage event:
1. When did the loss occur? (date, time):
2. When was the loss discovered? (date, time):
3. Where exactly did the loss take place (country, town/city, street as applicable)?
How did the loss occur? Please give a detailed description with all attendant circumstances (if necessary,continue on a separate sheet).

4. To what authority did you notify the loss?

□ Police □ Hotel/Tour Guide □ Airline □ Bus driver □ Campsite □ Rail-/Ferry comp.
inat (Date)

on

am/pm

Please send us the original police report and / or the original confirmations. When reporting the damage to theairline, please submit the airline's confirmation (PIR certificate) and the original flight and luggage tickets. If theclaim date differs from the date of the police report and / or the respective report or if no report was made, weask you for a detailed explanation.
5. What was the value of your luggage that was not affected by the claim (including items worn on your body) at
the time the damage occurred (current value)?
□ EUR

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HanseMerkur Reiseversicherung AG
Siegfried-Wedells-Platz 1, 20354 Hamburgwww.hmrv.deTravel Luggage Claim FormV.

Insurance no.

Loss of/damage to baggage while in the safekeeping of an airline:

Has an application for compensation already been made to the airline?

□ No □ Yes

Has the airline got a full list of the Lost baggage contents submitted?

□ No □ Yes, please send us copy’s

If so, to which airline?
Have you received compensation?

□ No □ Yes, the sum of(Please enclose proof)

Please submit not only the PIR certificate but also the tickets and baggage check-in stubs as well as theoriginal of the final confirmation of loss issued by the airline.
VI. Lost or damaged baggage
Please submit the original proofs of purchase, where necessary credit-card invoices, guarantee cards, fee receipts
for identification documents, confirmation from specialist dealers of the extent of damage (expertise), repair
invoices, instruction manuals for technical appliances.
ItemPurchase price in EUR When purchased
Month/year

Where
Proof of purchase Please do not write
purchased
yes/noin this column

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HanseMerkur Reiseversicherung AG
Siegfried-Wedells-Platz 1, 20354 Hamburgwww.hmrv.deTravel Luggage Claim Form

Insurance no.

VII. Lost or damaged baggage□ Car □ Kombi □ Cabriolet □ Camper □ Caravan □ Bus □ Motorcycle

Type of vehicle:
Model:

Year built:

Registration number:

Where was the vehicle at the time the loss occurred?

□ Car Park

□ Roadside□ Garage□ official campsite

The vehicle was parked there from□am/pm until

am/pm

Where were you during this time?
When was the theft discovered?
How was the car damaged by the break-in?
Please send us the repair invoice (copy).
Who owns the vehicle (name and address)?
Vehicle insurance (name and address of the company):
respective policy no.:Was the damage notified to the motor insurance company?

□ No □ Yes, respective police no.:Exactly where and how were the respective items stowed in the vehicle?
In the case of hired vehicles, please submit acceptance and return protocol.

VIII. General declarations:
1. What measures were taken to recover or restore the affected items?
2. Are there any witnesses that the damage occurred? (Names and addresses):

3. Have you yourself, or possibly those persons travelling with you, claimed for loss or damage of baggage orother valuables in the past? Please ensure that all previous damaging events are included and please also notethe personal declaration below.

□ No □ YesIf so, when?

(Name and address of the relevant person(s))

Compensation received?

With which insurance companies have claims been filed?
(Name, Address, policy-no., claim-no.)□ No □ Yes □ Not yet decided(If necessary, continue on a separate sheet)

4. Did you yourself or those persons travelling with you take out other insurance policies for baggage or valuab­
les for the period in question?

□ No □ Yes(Name and address of the relevant person(s))

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

Travel Luggage Claim Form

If so, please give names and addresses of insurance companies:
Policynumber:Has a claim been filed with such an insurance company? □ No □ Yes, claim-No.:
5. Do you have insurance cover for household and personal effects? □ No □ Yes, Policy-No.:
If so, please give name and address of the insurance company:
Have you filed a claim with that company?

□ No □ Yes, claim-No.:

6. Who should receive the claim settlement? (Name, address, bank account, IBAN, BIC, Swift, ABA)

Place, Date

Policyholder’s signature

IX. Original documents to be enclosed with the claim:□ Policy/proof of premium payment□ Police report□ Confirmation of notification from airline/transport company□ Booking confirmation□ Final confirmation of loss from airline□ Air tickets/baggage check-in stubs□ Purchase invoices of the affected items□ Repair invoice/s□ Fee receipts for identification documents□ Expertise□□ List of items not affected by the damage (form is attached)

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

Travel Luggage Claim Form

Information on the consequences of breach of duty after the insured incident has occurredInformation under Sec. 28 para. 4 VVG
Dear customer
After the insured incident has occurred, we require your assistance.
Duty to provide information and assist in clarification
On the basis of the contractual agreement entered into, we may ask you to provide us with all information that is necessary toclarify the scope of liability (duty to provide information) and to clarify the matter fully (duty of clarification) to enable us to
fully assess the claim. However, we may also request that you provide us with supporting documents, provided that such re­quests are reasonable.
Loss of benefits
If, contrary to the contractual agreements, you fail to provide us with information or give incorrect information, or wilfully failto provide us with the supporting documents that we request, you will lose your entitlement to compensation. If breach ofsuch obligations is based on gross negligence, we may reduce the benefits in proportion to the seriousness of the negligence.
There will be no reduction if you prove that you have not been grossly negligent in infringing the obligations.
Notwithstanding a breach of your obligation to either provide information, assist in clarification, or provide supporting docu­
ments, we are still obliged to pay compensation insofar as you can prove that any violation of duty was neither the result ofestablishing the scope of the insured incident or the scope of our liability.
If you fraudulently breach the obligation to provide information to clarify matters or to provide supporting documents, we willin every case be released from our liability to pay the claim.
Note:
If 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 documents.

Place

Date

Signature of policyholder and insured or legal representative
Final statement
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 insurance cover. I have taken note of the above information in accordance with Sec. 28 para. 4 of the Insu­
rance Contract Act (obligation after the insured incident).
In addition I assign my claims and demands against a third party causing the accident / liable party or against my statutory he­alth insurance fund / private health insurer to the amount of the compensation paid by HanseMerkur Reiseversicherung AGto HanseMerkur Reiseversicherung AG.

PlaceDate

Signature of policyholder and insured or legal representative

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