Claim Form PART C please send this medica report as soon as possible ‘to the claims department of hogast Italien! Fax: 629 0871 978118; E-Mail: crv@hogast it Policy no: Claim no. Eropatsche mmo Ho kel Condor ‘©. Doctor's certificate (to be completed by the doctor) {to be forwarded to Europaiche Reiseversicherung AG) ‘To confirm thatthe patient i unable to travel de to iliness/acedent/oreananey. ‘The insurer reserves the right to take egal ation If information is untrue, in cor ‘tending doctor Oy Gara Ble Paty Tie Fst ane ast name £32349 84 88P Phone Wauser Vswne Tile, Fist and Last name aly AL AA go bate afeien qrveldentnaton: St. Vic oy t\v 0 4. Precise diagnosis (please write legibly): % Oy Ackepneumonca bill please filinthe following form in fll and accurately dance with Section 146 ofthe Austrian Criminal Code (0. Urrthern strtovet Bele Suet Hous 000" jopes, Pwrdvan / (Cos pcote ch, Cooney Ae re ease sqret, Howe na, Doorn jose s, Paqvao, Cvs Zipcode, City, Country Dapature dare: (2 OD. ZO? Axyuvel Pibyiloavoy T 4 2, Course of therapy: +3. When did the patient become il/ When dd the accident occur / When was the diagnosis made? {in case of pregnancy: when was pregnancy detected) Hospital stay serpaiscne ai Form PART { fo ee OQ) wae Reported sick to your national health sevice provider: Lolo. Ve -t holo. Vavecetamsl [ory 42 oe. nt LV. Si one 45-82 927 No Yesefrom_ 2 , age tof———— Claim Form PART C ‘4.18 your patient unable to travel on this tH for medial reasons? no (_Yes}-When did patients inability to travel become apparent? Inthe event that a nontravelling family member (such as ite partner, cldren, parents, siblings) was affected _when di become apparent thatthe presence ofthe insured was urgently needed? Date swt because ofa preening eso the consequence of an acide? © « ‘6 Only tebe completed in the case of existing less or consequence of an accident: ‘asthe existing ness/consequence ofan acident become acute unexpectedly? NoYes ‘when di the iness/consequences of the accident fist occur? bate patient receiving in-patient treatment in connection withthe diagnosis stat C res @- THE TRA m (ed above (excluding check-up examinations)? THE POUCY WAST THE TRAVEL 80OKIN was the patient receiving eaten tretmentin connection with the drove above (ecg checkup examinations)? eae ‘So2ce or aditional comments: ‘s. ‘by seine. confirm thatthe above Information | have provided is accurate and complete undertake to provie the insurers medica offices a Ore ert abou te raeven mca fermationTheleoe env the gto tae nga ation fifa Ce ‘Decordance with Section 146 of the Austrian Criminal Code, whic decor sin the bet postion to prove intormatin about the inal