Van Breda Claim form

MasterCard insurance - Claim form
Read our FAQs
MasterCard used for the transaction*
Date of purchase*

DayMonthYear
Date
Items purchased prior to 01/01/2023 are not eligible.

Don't hesitate to contact us:

BVB-protection@qover.com

+32 2 588 25 50
Items and travels purchased prior to 01/01/2023 are not eligible.

Don't hesitate to contact us:

BVB-protection@qover.com

+32 2 588 25 50
What happened?*
What type of claim do you wish to submit?*
What happened? *
What happened?*
What happened with your luggage? *
ref_country
insurer
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You will need to upload the following documents:
Read our FAQs
Make sure you have those documents prior to going further on this claims form, otherwise you won't be able to submit the claim !
Invoice or receipt for the item

We require the invoice relating to the transaction you want to claim for. This must include the description of the item and the amount paid.
Police report

We require a report from the police detailing the theft and stating which items have been stolen.
Pictures of damaged item

We require picture(s) showing to what extent this item has been damaged.
Repair-invoice if the item has already been repaired

We require the invoice for any repairs.

Quote or formal statement from a repair shop if the item still needs to be repaired or is unrepairable
- In case your item is repairable, we require a quote from any repair shop
- In case your item cannot be repaired, we require a formal statement that the item cannot be repaired from any repair shop.
Invoice or receipt of the travel purchase

We require the invoice relating to your travel. This must include the description amount paid.
Photos of the damaged item delivered (if applicable)

We require photos showing to what extent this item has been damaged.

Proof that you have contacted the seller to try to resolve the delivery problem.
Trip cancellation proof

We require proof that your trip has been canceled and that the reason for the cancellation is valid.
Travel delayed

We require the proof that your travel has been delayed including the delayed schedule. The transport carrier can issue this proof for you.

Expenses invoice or receipt

We require all invoices and receipt to justify the neccessary expenses you made until you finaly arrive at your destination
Missed departure

We require proof of the cause of your missed departure.

Expenses invoice or receipt

We require all invoices and receipts to justify the necessary expenses you made until you finally arrive at your destination
Luggage delayed

We require the certificate from the carrier that your luggage has been delayed.

Expenses invoice or receipt

We require all invoices and receipts to justify the necessary expenses you made until your luggage finally arrived at your destination.
Luggage loss or stolen proof

We require the certificate from the carrier that your luggage has been lost or the police report attesting that your luggage has been stolen.

List of lost/stolen goods

We require the list of all lost/stolen goods and all invoices and receipts to justify them.
Damaged luggage picture

We require the pictures of the damage to the luggage and your damaged personal belonging.

List of damaged goods

We require the list of all damaged goods and all invoices and receipts to justify them.

Cardholder information

Please provide us the following details about the cardholder
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Country Code (example: +32)Phone Number
Birthdate*

DayMonthYear
Date
claimant_entityType
claimant_address_country

Incident details
What happened to your delivery?*
Incident description*
Explain what happened
Date of the incident*

DayMonthYear
Date
Incident location*
Country of the incident*
Do you have another insurance covering the same risk ?*

YesNo
Provide the name of the insurer and the contract number*
Please provide the police report made after the incident*

Cancelof
Please provide the proof that you have contacted the seller to try to resolve the delivery problem*

Cancelof
claim_type

Transaction

Transaction made with your MasterCard
Did you purchase the item online and/or via phone?*
Unfortunately, we only cover items purchased online or by phone. As a consequence, you are not able to file a claim for this item.

Don't hesitate to contact us:

BVB-protection@qover.com

+32 2 588 25 50
Name of the merchant the item was purchased from*
Name of the transportation company from which you purchased your trip*
Please provide as much contact information about the merchant as possible*
IBAN of your Van Breda account*
Provide here your bank account number in IBAN format
Total amount (including VAT)?*
Currency*
Is your item included in one of the exclusion categories listed below?*
Unfortunately, this category of item is excluded from the coverage. As a consequence you are not able to file a claim for this item.

Don't hesitate to contact us:

BVB-protection@qover.com

+32 2 588 25 50
Description of the item purchased*
Please provide the invoice or receipt of the transaction*

Cancelof
Purchase protection
Is it a total loss ?*
Description of the damage*
Upload the repair quote or total loss attest from the repairer

Cancelof
Upload the repair invoice if the item is already repaired

Cancelof
Upload pictures of the damage*

Cancelof

Travel issue

Please provide the information for the means of transportation booked with your MasterCard
Departure city & country*
Departure date & time*

DayMonthYear
Date
Hour Minutes
Destination city and country*
Return date & time*

DayMonthYear
Date
Hour Minutes
Transport means*
Number of the transport*
e.g flight number
Cancellation date*

DayMonthYear
Date when you notified the carrier and cancelled the trip
Delay duration*
Please enter a valid number in hours (e.g., 1.5 for 1 hour and 30 minutes).
Please provide a proof of the reason why you had to cancel your trip*

Cancelof
Please provide a proof of the delay of your means of transportation from or to Belgium*

Cancelof
Please provide a proof of the reason why you missed your means of transportation from or to Belgium *

Cancelof
Please provide proof of all travel and accommodation expenses that you have paid or are contractually obligated to pay

Cancelof
Please provide proof of theft/loss of your baggage/personal item*

Cancelof
Please provide the police report describing the incident*

Cancelof
Please provide a picture of the luggage/personal effect that has been damaged*

Cancelof
Please provide proof of the delay of your luggage and the costs you incurred as a result of the delay*

Cancelof

I hereby declare that I have answered the questions to the best of my knowledge, accurate, in accordance with the truth and not to have concealed any information relating to this claim; I am aware of the stipulation that any right to benefit may lapse with an untrue statement; I have knowledge of the contents of this form.*

I confirm
Should be Empty:

MasterCard insurance - Claim form

You will need to upload the following documents:

Cardholder information

Incident details

Transaction

Purchase protection

Travel issue