Personal Accident Report

How does the claims process work?

Speler Club Ethias

1 Speler

The injured member visits a doctor. Ask the doctor to fill out the Ethias claim form, or request a certificate from the hospital.

3 Speler U bent hier

The member fills out this online form.

4 Club

The club registers the claim with Ethias.

2 Speler

The member pays all costs upfront.

5 Ethias

Ethias contacts the member and provides a file number (dossiernummer).

6 Speler

The member requests a statement of difference (verschilstaat) from the health insurance fund (mutualiteit).

7 Speler

The member sends all invoices and the statement of difference to Ethias.

8 Ethias

Ethias processes the file and pays out the reimbursement.

One single form per accident is sufficient. A cover letter is not necessary. The file number will be communicated by Ethias after receipt. Have the claim form at hand, you will need the details of the victim and the accident to fill in the form correctly.

Don't forget to upload the doctor's certificate in the attachments. Without certificate your file cannot be processed further.

1 Identity of the Victim

* Title

* Name

* First name

Maiden name (if married woman or widow)

* Street

* No.

Box

* Postal code

* City

* Country

* Date of birth

* Gender

* Email

Occupation

* Bank account number (IBAN)

National register number

Legal representative (only fill in if victim is a minor)

Name

First name

Street

No.

Box

Postal code

City

2 Accident Details

* Accident date

* Accident time

* Location

During participation in an activity of the insured

On the way to or from the activity

* Exact location

Mode of transport (if on the road)

* Accident description

3 Involvement of Other Parties

Third party involved (if applicable)

Title

Third party name

Third party first name

Street

No.

Box

Postal code

City

Country

Third party date of birth

Insurance company of the third party

Third party policy number

Was the accident caused by the fault of another insured person?

Yes

Was the accident caused by a defect in the installations?

Yes

Was an observation made by a police authority?

Yes

4 Witness Statements

a) Name and address of witnesses

b) Name and address of persons who saw the situation after the accident (when no witness)

c) When and by whom did you learn of the accident? (in the absence of witnesses)

Attachments

You can upload photos of the accident, a traffic sketch, medical certificates, the official report or other relevant documents here. Allowed formats: PDF, JPG, PNG, DOC(X). Max. 10 MB per file.

Select files or drag them here

GDPR – Processing of health data

Based on the clause regarding the processing of health data, you give Antwerp Rugby Club and Ethias permission to process your health data or that of the cared for person for the management of the claims file. This consent can be withdrawn at any time.

* I give consent for the processing of my health data by Ethias

* Drawn up in (place)

* Drawn up on (date)