Claim Form

Claimant information

Claimant type* Claimant type*

Is claimant a private person or a commercial entity?

Private

Commercial

Is the claimant the policyholder or a third party?*

You/the claimant is a third party if you/the claimant is not the person who has taken out the policy. If you/the claimant has taken out the policy yourself select no

The claimant is a third party

The claimant is the policyholder

Name of claimant*

Date of birth*

Social security number*

VAT number*

VAT*

Address*

Country*

E-mail*

ClaimForm.Filer.CreditorMail.Label

Confirm e-mail*

Confirm email*

Confirm e-mail*

ClaimForm.Filer.CreditorMailConfirm.Label

Phone number

Please state your telephone number including country code - e.g. +4412345678

Claim information

Claimhandler*

Claim reference from claimhandler*

Claimed amount*

Select currency*

Date of loss / Claim date*

Claim description*

Policy information

Policy number / certificate number

Policy inception date

Policy Expiry date

Upload documentation

Documentation of the claims handlers rejection of the claim*

Upload documentation

Upload your policy document

Upload documentation

Upload your premium document

Upload documentation

Payment information

IBAN*

I solemnly declare and promise, based upon my good faith, knowledge and belief, that the information entered is correct

Please be aware that filing a claim at this web form does not entail, that your claim will be approved as covered by the policy. You may expect that the claim will be rejected in accordance with the claim handler’s decision.

You can get support on filling out the form by contacting claimssupport@qudosinsurance.dk Please note that this email *cannot* be used for submitting claims.

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