Claim Form
(Please print this page and complete details as applicable. The signed Claim Form should then be forwarded to Allianz at the address shown (in red) below together with the supporting documentation requested below.
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TicketPlan Master Policy Protection - Claim Form
Instructions for Ticketholder
1. Please complete your details in BLOCK CAPITALS.
2. After completing the form please forward it to:
Technical Claims Department, Allianz Schemes,
Allianz House, 6 Vale Avenue, CityTunbridge Wells, Kent, PostalCodeTN1 1EH.
Please note:
The Ticketplan Master policy protection is an insurance contract between Allianz Insurance plc and the Master Policyholder
shown in the Master Policy Schedule
All claims must be reported within 24 hours
Unused tickets and proof of the purchase of the Ticketplan master policy protection will need to be forwarded with this claim
Please answer all questions clearly and concisely to avoid misunderstanding or delay.
Your Details
Title ___________ Initials __________________ Surname __________________________________________________________
Address _____________________________________________________________________________________________________
____________________________________________________________________________________________________________
_________________________________________________________ Postcode _____________________________________
Telephone (Home) ___________________________________ Telephone (Daytime) _______________________________________
Event Details
Date of Booking _______________________ Theatre ________________________ Show________________________________
Cost of tickets __________________________________ Date of Show__________________________________________________
Details of persons due to attend performance
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
General Information
When did you become aware that you were unable to attend the event ____ _______________________________________________
Please identify why you were unable to attend the performance
Death/illness/accident/failure, delay or breakdown of public transport/breakdown, accident of private transport (delete as applicable)
Claim Details
Please complete the section which is relevant to your claim.
A. Bereavement - Please be advised we will need to have sight of the death certificate
Identity of the deceased ________________________________________________________________________________________
If not attending the performance please indicate their relationship to you _________________________________________________
Date and cause of death _______________________________________________________________________________________
Had this person been undergoing treatment for the condition which caused their death______________________________________
Had there been any change to this treatment within the last 2 months? If so please detail ____________________________________
___________________________________________________________________________________________________________
B. Accident - Please be advised we will require a doctor's note confirming details
Identity of the person who suffered the accident ____________________________________________________________________
If not attending the performance please indicate their relationship to you ________________________________________________
Nature of accident___________________________________________________________________________________________
When/how accident occurred__________________________________________________________________________________
Why did the accident prevent this person from attending the theatre____________________________________________________
C. Illness
Please note we will require a doctor's letter/note confirming you were not able to attend the performance,
the condition and if there had been any changes to the treatment in the 2 months prior to the booking
Identity of person suffering illness ________________________________________________________________________________
If this person was not attending the performance please indicate their relationship to you _____________________________________
Nature of illness ______________________________________________________________________________________________
When was this first diagnosed ____________________________________________________________________________________
Was this person undergoing treatment for this condition_______________________________________________________________?
If so had there been any change in the treatment within the past 2 months prior to the booking, if so please detail ____________________________________________________________________________________________________________
D. Breakdown of public transport or failure/delay due to strike
Please note we will require official notification of strike/breakdown from service provider
Details of those people in your party affected _______________________________________________________________________
Details of the journey __________________________________________________________________________________________
Details of dispute/strike ________________________________________________________________________________________
Please confirm when you became aware of the event giving rise to the claim ______________________________________________
E. Breakdown of Private Transport
Please note we will require a vehicle recovery service report or copy of garage repair bill
Details of vehicle concerned ____________________________________________________________________________________
Details of journey ____________________________________________________________________________________________
Details of when you left home __________________________________________________________________________________
Location of incident ___________________________________________________________________________________________
Time of incident ______________________________________________________________________________________________
Details of incident ____________________________________________________________________________________________
Declaration - To be signed by the customer for ALL claims
The above answers to our questions will be the basis of consideration of the Master Policyholder's claim under their Master Policy.
You must ensure that all information is true and correct to the best of your knowledge and belief, and that all material facts have been disclosed.
A material fact is one that is likely to influence us in the assessment or acceptance of this claim, or one that is likely to influence our consideration
of cover under the terms of this Master Policy. If you are in any doubt as to whether a fact is material, you must disclose it.
FAILURE TO DO THIS MAY MEAN THAT THE POLICY BECOMES INVALID
AND A CLAIM PAYMENT WILL NOT BE MADE.
I declare that the information I have provided above is true to the best of my knowledge. Any claim paid to the Master Policyholder as a result
of any knowingly incorrect statement made by me or on my behalf shall be invalid and may result in subsequent action being taken against me.
I agree that any copy made of this form shall have the validity of the original.
Signature __________________________________________________________ Date ____________________________________
Data Protection Notification.
The details you provide will be used by Allianz Insurance plc to administer this claim for the purpose of fraud prevention. We will not keep your details for longer than is necessary. You are entitled to a copy of all the information we hold on you, for which we may charge you £10.This insurance is underwritten by Allianz Insurance plc: Registered in England No. 84638. Registered Office: 57 Ladymead, Guildford, placeSurrey GU1 1DB
This insurance is underwritten by Allianz Insurance plc: Registered in England No. 84638. Registered Office: 57 Ladymead, Guildford, CityplaceSurrey PostalCodeGU1 1DB, country-regionUnited Kingdom. Administered by Allianz Schemes, addressStreet6 Vale Avenue, CityTunbridge Wells, PostalCodeTN1 1EH, country-regionUnited Kingdom. Allianz Insurance plc is authorised and regulated by the Financial Services Authority (FSA). Our authorisation can be confirmed by the FSA by calling 0845 606 1234 or at www.fsa.gov.uk. Our FSA registration number is 121849.
