ONLINE DECLARATION

Booking details

this is a required input
this is a required input
this is a required input
The address of the travel agent?

E-mail address and phone number of the travel agent or travel company?
this is a required input
this is a required input
Details of the insured person

this is a required input

this is a required input
this is a required input
this is a required input
this is a required input
this is a required input
this is a required input
this is a required input
this is a required input

Do you have other insurances that cover these costs such as a credit card or continuous cancellation insurance? this is a required input
this is a required input
Cancellation details

this is a required input
this is a required input
this is a required input
this is a required input
this is a required input
this is a required input
Reason for the cancellation


this is a required input
this is a required input
this is a required input
this is a required input
Person who caused the cancellation

The insured person
this is a required input
this is a required input
this is a required input
this is a required input

Was or is the person hospitalised? this is a required input

this is a required input
this is a required input
If cancelled due to a medical reason, the address of the patient during the recovery period if this is NOT the address of the insured person
Refund

To whom should the refund be made?

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Required documents

To settle a cancellation, we must receive the following documents:

  • Order form/Invoice
  • Cancellation invoice from the travel company mentioning the cancellation fees or any refund/credit notes from the airline for example
  • If cancelled due to a medical reason, the medical questionnaire completed by the doctor (link to the medical questionnaire)
  • For all other reasons, official documentary evidence
Closing statement

Would you like to explain the reason for the cancellation (nature of the illness, circumstances of the accident, reason for dismissal, etc.) at this time?

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The collected personal data will be processed by AG Insurance, the data controller, in accordance with the General Data Protection Regulation of 27 April 2016 and all other applicable Belgian data protection regulations. Personal data will be processed for the following purposes: claims handling. Where necessary, this data may be disclosed to third parties insofar as there is a legitimate interest to do so. The data may also be disclosed to any other third party or authority if there is a legal obligation to do so or if such disclosure has been mandated by court order or other administrative ruling. After collection and processing, the personal data will be retained for the duration of the claims handling process, the statutory retention period as well as any other required duration set by the governing laws and regulations. Within the limits of the applicable legislation, you have the right to access and to rectify the personal data held about you at any time. You also have the right to object to the processing of your data and to request the deletion of any data held about you. In doing so, however, AG Insurance may be unable to continue with the above-mentioned purposes. To exercise your rights, please send a signed, dated request to this effect along with a double-sided copy of your identity card by ordinary mail to AG Insurance, Data Protection Officer, 53 boulevard Emile Jacqmain, 1000 Brussels or by e-mail to AG_DPO@aginsurance.be. Additional information is available at the same address as well as in AG Insurance’s Privacy Notice posted on the website www.aginsurance.be.

Overview

Please look over all the details one last time. After that you can print and send the declaration.

1. Booking details













2. Details of the insured person














3. Cancellation details









€

€
4. Reason for the cancellation




5. Person who caused the cancellation




From until



6. Refund





7. Required documents

To settle a cancellation, we must receive the following documents:
  • Order form/Invoice
  • Cancellation invoice from the travel company mentioning the cancellation fees or any refund/credit notes from the airline for example
  • If cancelled due to a medical reason, the medical questionnaire completed by the doctor (link to the medical questionnaire)
  • For all other reasons, official documentary evidence
8. Closing statement