Claim Notice

1. Insured and Policy Information

Insured Name / Insured Business Name *

Insured Domicile *

Insured ID Number *

Policy Number and Item *

Certificate Number

2. Insured Contact Information

Name of Person to Contact *

ID Number *

Address

Telephone

Mobile Phone *

E-mail *

Repeat E-mail *

3. Claim Information

Date of Ocurrence/Date when ocurrence was acknowledged *

Time of Loss (if known)

Place of the occurrence/Location *

Facts (detailed description) *

Cause (if known)

Damages (if known)

4. Claimant (if different from insured)

Name

ID Number

5. Authorization for Notification Purposes *

As per established in article 30 of Decree 1055 of the Ministry of Treasury, published in the Official Gazette of December 29, 2012, I hereby authorized and grant express consent to Everest Compañía de Seguros Generales Chile S.A., so all notifications and communications to the insured, including those related to claims, shall be send to the e-mail address indicated in this Form, constituting the exclusive mean of communication for all notification purposes. This authorization will be valid and will govern unless the insured opposes to such form of notification. In case the insured opposes, communications must be made by registered letter addressed to the domicile of the insured indicated in this claim notice, or failing that, to the address registered in the respective insurance policy.

I authorize
I object

6. Personal Data Treatment *

Everest Compañía de Seguros Generales Chile S.A. hereby declares that, all information delivered by the Insured on the reported event, will be handled with absolute confidentiality and for the sole purpose of the analysis required for the settlement of the event, especially for the evaluation of coverage and payment of the claim giving strict and full compliance with the applicable regulations on the matter. Also, the Insured grants express consent to Everest to submit this claim notification and associated data to the official adjuster nominated by Everest to adjust the case, and authorizes Everest to process personal data for the purposes and within the scope indicated.

I authorize