European Claim Form

Lease organization

Name *
Contract number *

Applicant

Surname *
First Name *
Company Name *
Address *
Postal Code *
Town *
Country *
Telephone
Fax *
E-Mail

Asset

If several assets are damaged/stolen, please fill in the following information per asset in a Word or Excel sheet and e-mail this, in attachment to the claims notification, to Marsh, Léa De Ruyck. We also invite you to mark the right compartment in the section "Appendices".

Asset description *
Brand *
Serial Number
Econocom reference nbr
Purchase value
(see invoice)

Comments *

Description of accident/damage & location.
Date
Time
Cause
Do you have an other insurance? (yes/no)

Appendices

Please select from the available appendices those that are appropriate to your situation.

-> In case of burglary : *

Official Report (Police)
Vendor's offer for replacing asset
Proof of burglary damage (pictures, repair invoice of the burglary damage)
Word/Excel sheet of the stolen assets

-> In case of damage :

Repair company's estimate for cost of repair
Word/Excel sheet of the damaged assets

Date

*
Format: YYYY-MM-DD

Town

*

In order to have your claims notification handled, you should take the following steps, within 2 weeks after the date of burglary/damage :

1. Fill out completely the above claim form, including the appendices;
2. Print and/or export the claim form first before clicking on "Submit Survey";
3. Approve the claim form again or fill out the missing required data fields (marked with *);
4. Fax the printed claim form together with the official police report as soon as possible to the fax number below;
5. Fax, at the latest 1 month after the burglary or damage, a copy of the claims notification and its attachments to the following fax number :

    N.V. Marsh
    Att. Léa De Ruyck
    Fax: +32 2 674 99 34

We can only accept your claim if we receive all the necessary documents within 1 month after the burglary/damage.

If you have any questions, please contact us:

Post: N.V. Marsh
        Att. Léa De Ruyck
        Vorstlaan 2
        B-1170 Brussel
        Belgium

Telephone:+32 2 674 91 54
Fax:         +32 2 674 99 34
E-mail:      lea.deruyck@marsh.com

Surname	*
First Name	*
Company Name	*
Address	*
Postal Code	*
Town	*
Country	*
Telephone
Fax	*
E-Mail

Asset description	*
Brand	*
Serial Number
Econocom reference nbr
Purchase value (see invoice)

Description of accident/damage & location.
Date
Time
Cause
Do you have an other insurance? (yes/no)