Accident/unexpected Illness declaration form

    Please make sure to complete this form accurately to receive an effective and fast service.

    Along with the form, please also attach:

    • a copy of a medical report that details the medical diagnosis
    • copies of paid receipts

    If you do not have these documents now, you can send them at a later stage.

    Insured Member Details

    Local phone contacts

    Place and time of the accident/unexpected illness

    Type of accident/unexpected illness

    Diving accident

    The accident/unexpected illness occurred while

    Scuba diver information

    Scuba diving accident / unexpected illness

    Scuba diving information - Confirmed or suspected DCI

    Did you fly during the 24 hours before the dive?
    Did you take any medical treatment / drugs before the dive?
    Deco dive
    O2 Percentage
    %
    O2
    %
    He
    %
    Diluent
    O2:
    He:
    Set point
    Descent PPO2
    At depth PPO2
    Ascent PPO2
    Dive computer
    Electronic dive log available
    Did you breathe normobaric oxygen?

    Other underwater

    * Symptoms before the dive

    Dive info

    * Max depth
    m.
    * Total dive time
    min.
    Rapid ascent

    Freediver information

    * Certified freediver

    Freediving accident happened while

    What was the maximum depth of the accident dive?
    m.
    Dive computer
    Electronic dive log available
    * Symptoms before the dive

    Accident / Unexpected illness details

    Shortly describe the events that lead to the accident and/or the evolution of the symptoms that resulted into the unexpected illness (max 1500)

    Have you already received medical care?

    Details

    Phone contact

    Additional medical insurance

    Kind reminder: The insurance you hold with IDA Insurance Ltd as a member of DAN Europe is a secondary insurance cover to the National/European health cover you might be entitled to and any private travel or medical insurance you might hold. The insurers of IDA Insurance Ltd remain at complete disposal to evaluate the cover of any cost that falls out of other covers you might have.

    ×
    Phone contact
    * Was the accident notified to the insurance?
    I danAgreement in a representative of DAN Europe to notify the case to my other insurance

    Documents

    If available you can upload the following upload_File directly here, alternatively you can also send them via email on a later stage:

    • pictures of the affected area (if it applies)
    • medical reports
    • tests results
    • paid receipts
    • copy of a proof of the start of your journey (in case of non diving accident abroad)
    Please note that the maximum allowed size of attachments is 20MB

    This form has been completed by:

    Details of the person who completed this form

    Local phone contacts

    Summary

    Insured Member Details







    Place and time of the accident/unexpected illness




    Arrival date in this country
    You are in this country for

    Excluding this trip, have you travelled abroad in the last 12 months?

    Type of accident/unexpected illness

    Diving accident

    The accident/unexpected illness occurred while

    Scuba diver information







    Scuba diving information - Confirmed or suspected DCI

    Did you fly during the 24 hours before the dive?
    Did you take any medical treatment / drugs before the dive?



    Deco dive




    O2 Percentage
    O2
    %
    He
    %





    O2 Diluent
    He Diluent
    Descent
    At depth
    Ascent

    Dive computer

    Electronic dive log available




    Did you breathe normobaric oxygen?

    First dive

    Max depth
    m.
    Total dive time
    min.
    Rapid ascent
    Surface interval
    min.

    Second dive

    Max depth
    m.
    Total dive time
    min.
    Rapid ascent
    Surface interval
    min.

    Third dive

    Max depth
    m.
    Total dive time
    min.
    Rapid ascent
    Surface interval
    min.

    Fourth dive

    Max depth
    m.
    Total dive time
    min.
    Rapid ascent
    Surface interval
    min.

    Fifth dive

    Max depth
    m.
    Total dive time
    min.
    Rapid ascent
    Surface interval
    min.

    Sixth dive

    Max depth
    m.
    Total dive time
    min.
    Rapid ascent
    Surface interval
    min.

    Seventh dive

    Max depth
    m.
    Total dive time
    min.
    Rapid ascent
    Surface interval
    min.

    Eighth dive

    Max depth
    m.
    Total dive time
    min.
    Rapid ascent
    Surface interval
    min.

    Nineth dive

    Max depth
    m.
    Total dive time
    min.
    Rapid ascent
    Surface interval
    min.

    Tenth dive

    Max depth
    m.
    Total dive time
    min.
    Rapid ascent
    Surface interval
    min.

    Scuba diving information - Other underwater



    Symptoms before the dive

    Dive info

    Max depth
    m.
    Total dive time
    min.
    Rapid ascent

    Freediver information

    Certified freediver





    Freediver information - Underwater





    What was the maximum depth of the accident dive?
    m.
    Dive computer

    Electronic dive log available
    Symptoms before the dive

    Accident / Unexpected illness details

    Shortly describe the events that lead to the accident and/or the evolution of the symptoms that resulted into the unexpected illness
    Have you already received medical care?

    Details


    City and Nation
    -

    Phone contact

    City and Nation
    -

    Phone contact

    City and Nation
    -

    Phone contact

    Additional medical insurance




    Phone contact

    Was the accident notified to the insurance?

    I danAgreement in a representative of DAN Europe to notify the case to my other insurance


    Phone contact

    Was the accident notified to the insurance?

    I danAgreement in a representative of DAN Europe to notify the case to my other insurance


    Phone contact

    Was the accident notified to the insurance?

    I danAgreement in a representative of DAN Europe to notify the case to my other insurance

    Documents

    Details of the person who completed this form



    Local phone contacts


    Important Data Protection Notice:
    The Insurer and its affiliates process personal data in accordance with the provisions of the applicable Data Protection legislation and accordingly accept your authorisation to process such data for the following purposes or for any other purpose not incompatible or inconsistent with this legislation:
    i. Updating records (manual or electronic) of the Insurer and/or its affiliates;
    ii. Administering your insurance policy, underwriting, handling and settling of claims, detecting, preventing and suppressing of fraud and keeping statistics on an anonymous basis;
    iii. Transferring data between the Insurer and its affiliates, including VING Insurance Brokers Ltd and Divers Alert Network (DAN) Europe;
    iv. Obtaining medical information about you and accordingly accepts your authorisation for any doctor, hospital, laboratory or other insurance provider to disclose full information about you to the Insurer and/or any of its affiliates;
    v. Informing you, without being obliged to do so, of any new services provided by us or any changes in the law, policy or practice which may be of interest to you by email, fax or other electronic means.
    You also declare that you understand that you have the right to request access to your personal data.