LifeStyle-Excess Claim Form

If you are claiming against your Lifestyle-Excess Policy please take a few moments to complete the form below. On completion please read and accept the Declaration by checking the tickbox. Then click the 'Proceed' button at the bottom of this page and your details will be electronically sent to the Claims Administrator, AXA Assistance.

Original Certificate No.
If you cannot locate your certificate and you don't know the certificate number, please call the broker/website where you purchased the Lifestyle-Excess policy.
Where did you purchase the Lifestyle-Excess cover?
Policy Inception Date
Click on icon to access calendar
Under what section do you wish to make a claim?
        
Policy Limit

Contact Details

Title
Forename
Surname
Address
Post Code
Email Address
Contact Telephone No.
(This will only be used if we have problems contacting you, for example - emails being blocked/down)
Age of Policy Holder

Your Lifestyle-Excess Insurance Policy Details

Have you previously made a claim under this Lifestyle-Excess Policy?
  
On receipt of this claim form by AXA Assistance they will verify your certificate information. If you have previously claimed during this policy period they will calculate what indemnity excess still remains in force. Only the remaining balance will be claimable.

Claim Details

Incident Date
Click on icon to access calendar
Please state the amount of excess that you are claiming £
(this figure must match the excess you are responsible for on your settlement letter from your Insurance Company)
Country of Incident

Are you claiming as the Policy Holder?
  
If no please complete the additional claimant details below.
Title
Forename
Surname
Address
Post Code
Email Address
Age of Claimant if not Policy Holder
Please Name Your Main Insurance Provider
Main Insurer's Telephone No.
Claim Number / Reference Number
Type of Domestic Pet
Other (if not above)
Was your Home occupied at time of Incident?
  
Type of Incident
Other (if not above)
Time of Incident
Type of Travel Incident
  
  
  
Other (if not above)
Vehicle Make
Vehicle Model
Year of Manufacture
Type of Incident
Time of Incident
Type of Insurance
Was the vehicle used for Social, Domestic, Pleasure & Commuting?
  
THIS POLICY WILL ONLY RESPOND TO SOCIAL, DOMESTIC, PLEASURE & COMMUTING MOTOR CLAIMS.

IMPORTANT INFORMATION FOLLOWS

There are two methods of your claim being paid - please select your preferred method of payment

Bank Details

Please note that any settlement made by us would be via a bank transfer directly to the appropriate bank account. Accordingly please provide the following information:
Full Name and Address of Bank
Account Name
Account Number
Sort Code
Routing / Swift Code
(if applicable)

Cheque

A cheque will be made payable to the named insured and sent to the address as detailed in this claim form.

Declaration

Please Note; By ticking this box you are providing us with your authority to communicate with your main policy insurer to further validate the claim where necessary and obtain the details of any third parties who we may approach, if applicable, for the subrogation of your claim under this Lifestyle-Excess policy. The information supplied to us by you may be held on computer and passed to other insurers for underwriting and claims purposes. When you tell us about an incident we will pass information relating to it to a database. We may search these databases when you have a claim to validate your claims history or that of any other person or property likely to be involved in the policy or claim. In order to prevent and detect fraud we may at any time: Share information about you with other organisations and public bodies including the Police; Check and/or file your details with fraud prevention agencies and databases, and if you give us false or inaccurate information and we suspect fraud, we will record this.

If you do not wish to proceed with submitting your claim online or require an explanation for regarding some aspect of this statement please call 0845 271 2467.

NEXT STEPS

  1. Please check that all the details that you have supplied are correct
  2. When the details have been received by us (AXA Assistance) we will respond by emailing a letter confirming receipt of your details which will include a claim reference number, which you must use in all future correspondence with us.
  3. You now must send to us, upon receipt of the letter from AXA Assistance confirming they are dealing with your claim, the following documentation:
    1. A copy of your Lifestyle-Excess Reimbursement Certificate of Insurance.
    2. A copy of your settlement letter from your Insurance Company, which must state the amount settled and the excess deducted.
Please return the requested documents to:

AXA Assistance Limited
PO Box 54098
London SW20 8UU

Tel: 0845 271 2467
Email: lifestyle-excess@axa-claims.com

Please allow 10 working days from the date you post this to AXA Assistance for them to process your claim. We recommend that you take full copies of this form and the documents enclosed.