Claim Form

Click here to download medical certificate.
Certificate Number*
Address*
Postcode / Zip*
Town*
Day/Time/Phone*
E-mail*

Payment

We pay direct to your personal account or by US$ check
Bank*
First and Last name of the account holder*
Account Number*
Swift/BIC*
Iban Number*
First and Last Name*
Date of Birth*

Cause of cancellation

First and Last Name*
Date of Birth*
One of the certificate holder*
Other co traveler*
Not a co traveler relation to the certificate holder*
Describe the reason why you have to cancel*
Details of Reservation/Cancellation

Details of Reservation/Cancellation*

Did you fully pay for your travel? if yes when?*
When was the reservation/booking made?*
When did the event occur that lead to your cancellation?*
Did you cancel*
If not canceled right away what was the reason?*
Specification of the claim for compensation*
Amount of loss*
Does the amount concern sevaral persons. if yes how many?
Have you received any compensation from your Travel Agent?

Signature

DateDate*
Signature(please type your First and Last name into this field.)*
Security code
Security code