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Pandi_claim_form_Crew

The document is a claim form for reimbursement that emphasizes GDPR compliance by not including personal-sensitive information. It requires supporting vouchers and invoices to be submitted separately and outlines various categories of expenditures that can be claimed. Additionally, it includes sections for remittance details and beneficiary information.

Uploaded by

Subhasis Bhattacharya
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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14 views2 pages

Pandi_claim_form_Crew

The document is a claim form for reimbursement that emphasizes GDPR compliance by not including personal-sensitive information. It requires supporting vouchers and invoices to be submitted separately and outlines various categories of expenditures that can be claimed. Additionally, it includes sections for remittance details and beneficiary information.

Uploaded by

Subhasis Bhattacharya
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Claim form - Reimbursement

To ensure GDPR compliance and avoid unnecessary delay in paying your claim, please do not
include person-sensitive information on this form. Supporting vouchers/invoices to be submitted as
a separate attachment, and not as part of the Claim Form.

Vessel name Date of


Incident
Disability
Port of Disembarkation % Rate
(If applicable)

Date of Fitness Member Ref.

Final claim Yes No Gard Ref.

Details of expenditure
.

*Supporting
voucher Invoice Invoice Policy Claimed
Number Currency Amount Currency Amount
Medical Expenses

Sick Wages

Repatriation Expenses

Substitute Expenses

Claim Settlement

Disability Compensation

Death Compensation

Funeral Allowance

Maintenance and Cure


Personal Effects

Diversion Expenses

Escort
Termination Pay

Gross Amount Claimed


Less Social Security/
Other Insurances

Total claimed amount


Remittance Details:
If the beneficiary and the bank are in different countries, we may, for KYC-purposes, need
to collect additional information. This includes a dated statement (not older than 12
months) from the beneficiary bank confirming that the beneficiary is the sole holder of the
bank account.

Beneficiary Name

Beneficiary Address (full)

Beneficiary Company’s

Organization Number.

Account Number

Bank Name

Bank Address (full)

Bank’s Organization

Number

Receiver of Payment
Confirmation
(E-mail address)

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