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Insurance indemnity form

With * marked fields are mandatory.

 

1. Information on the insurance event

What happened and in what circumstances

Please, describe which part of the body has been injured

What happened and in what circumstances

2. Information on the application and the policy

Fillable if number is known

If the contract is concluded by the employer

3. Medical information

Doctor, who knows the health of the victim in relation to the accident.

4. Documents attached

The documents necessary for the assessment of the insurance indemnity, which you will mark, should be sent to .

After completing the form, you will receive instructions on how to encrypt copies of documents for safer mail.

The documents necessary for the assessment of the insurance indemnity, which you marked, should be sent to .

5. Requisites for reimburesement

I am informed that AAS SEB Dzīvības apdrošināšana can process data on my state of health, if it is necessary for making a decision on the payment of insurance indemnity or on the amount of compensation. In order to verify the occurrence of an insured risk and the amount of losses, the Insurer has the right to verify the necessary information by requiring information from the state and local government authorities or from other persons, including medical institutions and persons who may have such information. I am informed that payment of the indemnity may be refused by the Insurer in the case of the provision of false information. Detailed information on the categories of processed data, the purposes and timing of processing them, and other data processing related issues are summarized in the Data Processing Principles, which you can read at customer service locations and at seb.lv.

I commit to keep the originals of the documents attached to the application until payment of the indemnity has been made and submit them at the request of the Insurer. The Insurer reserves the right to request the applicant for the indemnity to appear personally at the customer service center of AAS SEB Dzīvības apdrošināšana.

We inform you that the information related to the insurance indemnity will be sent electronically by the Insurer to the e-mail indicated in this application. If I have chosen to use unencrypted e-mail for communication, I confirm that I am aware that the chosen e-mail is not a completely secure communication channel.

I agree that AAS Dzīvības apdrošināšana uses the telephone number and e-mail indicated in the application for further communication.

 

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