YOUR PERSONAL DATA

By submitting this form, I hereby certify that the information provided, including the monetary value for the items claimed is complete, true and accurate, to the best of my knowledge. I understand that the information provided may be subject to review and investigation and that Aircalin may disallow any claim which contains insufficient information, misrepresentation or false statements concerning whether or not previous claims have been made with Aircalin, an insurance company or another. I hereby give Aircalin the authority to request any documents or statements in relation to this claim to any relevant third parties such as insurance companies, retailers.