Refund_ home emergency - Global Assistance

REQUEST FOR A REFUND
of costs of home emergency assistance services

Personal details of the individual filing the request:

First name *

Last name *

Mailing adress *

E-mail *

Telephone *

Bank ccount number *

Real property details

Street *

Town/city *

Apartment number

Details of the insurance:

House number / street number *

Postcode

Floor

Housing cooperative / management company

Details of the insurance:

Insurance company* *

Insurance policy number *

Did you contact GLOBAL ASSISTANCE’s roadside assistance centre?

YES

Date of call

Time of call

What telephone number did you call from?

What telephone number did you call?

File number as kept by GLOBAL ASSISTANCE

If you were unable to contact GLOBAL ASSISTANCE, please provide the reason why. An explanation of why assistance was not arranged and/or paid in the standard way – that is, by contacting and requesting assistance from GLOBAL ASSISTANCE’s home emergency assistance centre – should be included in the event description.

Event details:

Date of the event *

Please, attach to this request the invoice and/or receipt issued by the company that provided assistance services. *

Choose a file

Event description and notes