Claim Notice

1. Background of the Insured and Policyholder

Name / Company name of the Insured *

Address of the Insured *

RFC (legal entity) or INE / CURP (individual) *

Policy Number and Item *

Certificate No

2. Insured's contact information

Name of contact *

RFC (legal entity) or INE / CURP (natural person) *

Address

Telephone

Cellular phone *

E-mail address *

Repeat E-mail *

3. Claim Details

Date of occurrence/Date of knowledge of the event *

Time of Incident (if known)

Place of loss/location *

Facts (detailed description) *

Cause (if known)

Damages (if known)

Estimated Amount

4. Claimant (if different from insured contact, broker or agent)

Name

RFC (legal entity) or INE / CURP (natural person)

E-mail address

Telephone

5. Consent of the holder of personal data *

The owner of the data hereby declares that he/she knows and fully understands the content, purposes and scope of the privacy notice that Compañía de Seguros Generales Everest México, S.A. de C.V. (hereinafter Everest) has for the relationship with its policyholders, and therefore grants his/her full consent for Everest to carry out the processing of his/her personal data in terms of said notice. At the same time, you agree that the payment of the premium of the insurance contract that you enter into or have entered into with Everest, as well as any declaration of loss, claim, or other acts related to said contract shall be considered as an unequivocal sign of the express consent you have given for Everest to carry out the processing of your personal data in terms of the aforementioned privacy notice

I authorize

6. Processing of Personal Data *

The Personal Data and Sensitive Personal Data of our clients will be processed for the sole purpose of the analysis required for the settlement of the claim, as well as to comply with the obligations derived from the insurance contract entered into in accordance with the provisions of the Insurance Contract Law and the applicable regulations, as well as the service, maintenance, renewal, support and advice during the contractual relationship with the insured and the attention and report of claims; to comply with any obligation derived from the present or future legal relationship between the client and Compañía de Seguros Generales Everest México, S.A. de C.V., S.A. de C.V., as well as the response to Mexican and foreign financial and judicial entities or authorities, in order to comply with the obligations derived from laws or international treaties.

I authorize