Reporting an insurance event for foreigners

Report insurance events

Notifier
Oznamovatel

Name
Jméno

Surname
Příjmení

Title before

Title after

Contact phone

Are you reporting the incident for yourself or someone else?

for myself for another

What is the relationship to the insured / injured person

Sales representative number

For company

In what relationship?

Company name

Name of insurance company

In what relationship?

Contract

Insured contract number

Cause

Event

Date of event

Event time

State

Place of origin of the event

Data of the insured (for which you are announcing)

NIN/date of birth

Name

Surname

Title before

Title after

Preferred method of communication

electronic communication postal communication

Contact e-mail

Contact phone

I don't know the contact phone

State

Zip code

Township

Street

Descriptive/indicative

Legal representative of the insured child (for which you are announcing)

Same as "Notifier"?

YES NO

Title before

Name

Surname

Title after

Street

Descriptive/indicative

Township

Zip code

State

NIN/date of birth

Contact phone

Contact e-mail

Event

Date and time the event occurred

State of the event

Place of origin of the event

Event description - cause of illness

Description of the disease

Diagnosis

The insured person was being treated for the same or similar diseases in the past?

YES NO

When and where has the treatment been in the past?

Was the disease due to alcohol or other addictive substances?

YES NO

Is the insured person insured with other commercial insurance companies?

YES NO

Select the name of the insurance company

Communication with the assistance service

YES NO

Have you had any problems before?

YES NO

Since when and what difficulties?

Address of the medical facility where the first treatment took place

State Medical Facility

Is the date of the first treatment the same as the date of the event?

YES NO

Date of first treatment

What treatment is this? - outpatient

YES NO

Were you prescribed prescription drugs?

YES NO

Hospitalization?

YES NO

Hospitalization from

Has the hospitalization already been finished?

YES NO

Hospitalization to

Transport or transportation to - from a medical facility or from - to the Czech Republic?

YES NO

Claiming health insurance in the Czech Republic

Claiming medical expenses insurance in the Schengen area

Expenditure

Currency

Period of stay of the insured abroad

Date of departure from the Czech Republic

Date of arrival in the Czech Republic

Claiming from Hospitalization Insurance

Was hospitalization due to pregnancy?

YES NO

What week of pregnancy did the event occur?

Contact to your gynecologist(s) where you are going during pregnant

Where did the hospitalization take place?

Same as first treatment Elsewhere

Medical devices

Has the hospitalization already been finished?

YES NO

Hospitalization from

Hospitalization to

Claiming Dental Treatment Insurance

The date of the 1st dental treatment is the same as the date of the event

YES NO

Date of dental treatment

The address and contact of the dentist who performed the treatment is the same as the address of the medical facility that provided the treatment

YES NO

Contact to dentist

Claiming insurance from outpatient medicines

Expenditure

Currency

Event description - cause of the accident

Detailed event description

Diagnosis

Which part of the body was injured?

Was this part of the body injured before the injury?

YES NO

When and where has the treatment been in the past?

Is the date of the first treatment * the same as the date of the event?

YES NO

Date of first treatment

Address of first treatment

Was there subsequent treatment at the site of the first treatment?

YES NO

Where did the follow-up treatment take place? (Addresses of all medical facilities and names of wards or addresses of surgeries and names of doctors)

Is the insured person an athlete?

YES NO

In what sport?

Name of the sports club

At what level?

Was there an accident under the influence of alcohol or other addictive substances?

YES NO

Was there an accident through someone else's fault?

YES NO

By who?

Did you have an accident in a car accident?

YES NO

File no. / Make / name and address of the relevant police department

Was the accident investigated by the police?

YES NO

File no. / Make / name and address of the relevant police department

Is the insured person insured with other commercial insurance companies?

YES NO

Select the name of the insurance company

Transport or transportation to - from a medical facility or from - to the Czech Republic?

YES NO

Claiming health insurance in the Czech Republic

Claiming medical expenses insurance in the Schengen area

Expenditure

Currency

Period of stay of the insured abroad

Date of departure from the Czech Republic

Date of arrival in the Czech Republic

Claiming Dental Treatment Insurance

The date of the 1st dental treatment is the same as the date of the event

YES NO

Date of dental treatment

The address and contact of the dentist who performed the treatment is the same as the address of the medical facility that provided the treatment

YES NO

Contact to dentist

Claiming permanent action by accident

Date of termination of injury treatment

What lasting consequences did the injury leave?

Date of stabilization of health

I don't know

Claiming a fatal accident

Is the date of death the same as the date of the event?

YES NO

Date of death

Diagnosis

Where did the insured person die (place)?

Name and address of the insured person's last general practitioner?

Name, address and telephone number of the notary authorized to carry out the acts of succession

Authorized person

Title before

Name

Surname

Title after

Street

Descriptive/indicative

Township

Zip code

State

NIN / ID

Contact phone

Contact e-mail

Claiming from Hospitalization Insurance

Where did the hospitalization take place?

Same as first treatment Elsewhere

Medical devices

Has the hospitalization already been finished?

YES NO

Hospitalization from

Hospitalization to

Description of the event - the cause of pregnancy and childbirth Claiming pregnancy or childbirth

You must check the claim

Is the date of treatment the same as the date of the event?

YES NO

Date of treatment

What treatment is this? - outpatient

YES NO

Hospitalization?

YES NO

Was hospitalization due to pregnancy?

YES NO

What week of pregnancy did the event occur?

Contact to your gynecologist(s) where you are going during pregnant

Was there hospitalization for childbirth?

YES NO

Is the date of birth the same as the date of the event?

YES NO

Date of birth

Medical facility where the birth took place

Give a reason for hospitalization

Where did the hospitalization take place?

Has the hospitalization already been finished?

YES NO

Hospitalization from

Hospitalization to

Is the insured person insured with other commercial insurance companies?

YES NO

Select the name of the insurance company

Communication with the assistance service

YES NO

Event description - cause of prevention I claim reimbursement of costs from the insurance of the Above Standard of Health Insurance of Foreigners

I claim from a preventive examination

Claiming Dental Treatment Insurance

The date of the 1st dental treatment is the same as the date of the event

YES NO

Date of dental treatment

The address and contact of the dentist who performed the treatment is the same as the address of the medical facility that provided the treatment

YES NO

Contact to dentist

Check at least 1 option

Event description - cause Liability - damage caused Claim from Liability Insurance

Type of injury

on cheers

Description

In what medical facility was the first treatment provided?

on property

Description and extent of damage

Estimated amount of damage

Payment of insurance benefits

financial damage

Description and extent of damage

Estimated amount of damage

on live animal

Description and extent of damage

Estimated amount of damage

other

Description and cause of injury

Estimated amount of damage

Payment of insurance benefits

Check at least 1 option

Witnesses to the event

Was the incident investigated by the police / fire brigade?

YES NO

While saved

Office address

Reference number

Who caused the damage?

The culprit the same as the insured?

YES NO

Title before

Name

Surname / Name

E-mail

Phone

Title after

Street

Descriptive/indicative

Township

Zip code

Birthdate

Damaged

Title before

Name

Surname / Name

Street

Descriptive/indicative

Township

Zip code

State

NIN / ID

Contact phone

Contact e-mail

Relationship of the insured to the injured party

Method of payment and insertion of documents

to account voucher

Is this a domestic account?

YES NO

NOTIFICATION:
The bank account number must always be confirmed by an entitled person and must be attached to other event reporting documents, using one of the following options:

A scanned or photographed account number, or an account number written on paper (not a bank card) with the number of the insurance policy, the name of the entitled person with his/her handwritten signature and the date of signature

An employee of Pojišťovna VZP, a.s. sale point will verify in writing that the submitted account number belongs to the entitled person (according to his/her identification card, such as a driving licence, a passport etc.), that there is a signature, a date of signature, the legible name of the sale point employee who verified the account number and this document can be attached to the reporting documents or it can be sent by email to oznameni.udalosti@pvzp.cz together with the number of the report, the number of the claim or the insurance policy.

This will speed up the claim settlement process. In case of failure to provide documentation, a loss adjuster will send a request in writing.

Account prefix

Account number

Bank code

Account holder

Currency

IBAN

SWIFT

Is she the same as the insured?

YES NO

NIN / ID

Name

Surname

Title before

Title after

State

Zip code

Township

Street

Descriptive/indicative

Contact person

It is the same as

insured authorized person legal representative

NIN/date of birth

Name

Surname

Title before

Title after

Preferred method of communication

electronic communication postal communication

E-mail

Contact phone

I don't know the contact phone

State

Zip code

Township

Street

Descriptive/indicative

Loading documents

NOTICE on restrictions on loading documents
Inserted attachments larger than 30MB in total may not be transferred correctly.
Documents can also be sent via the e-mail address oznameni.udalosti@pvzp.cz or to the address of Pojišťovna VZP, a.s. with the event number or report number.

Attach to the report or please send us these documents as soon as possible to expedite the liquidation investigation

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