This website is published and operated by CLAIM ASSISTANCE (hereafter « CLAIM ASSISTANCE »), a French limited liability company registered with the Bobigny Companies Register under number 803 147 446, with share capital of 200 000 euros and having its registered office 19, rue Honoré d’Estienne d’Orves 93500 Pantin, FRANCE.
CLAIM ASSISTANCE intercommunity VAT number is FR883803147446.
REFUNDMYTICKET is a registered trademark at the French National Institute of Industrial Property (INPI).
CLAIM ASSISTANCE offers on its website an amicable recovery service of debts due to passengers under Regulation (CE) n° 261/2004 dated 11 February 2004 or the Montreal Convention dated May 28 1999, granting to flight passengers a right to compensation and assistance in the event of denied boarding and of cancellation or long delay flights. Any judicial proceedings shall be initiated by an Attorney in accordance with the provisions of these general terms and conditions.
CLAIM ASSISTANCE assists the claimant in order to facilitate the recovery proceedings and will receive payment only in the event of success of the claim. CLAIM ASSISTANCE advances any and all fees and expenses related to the debt recovery. Those fees and expenses shall not be claimed to the claimant in case of failure of the recovery proceedings.
The conditions of use of the services offered on the website are set out below.
CLAIM ASSISTANCE can be contacted via the online contact form or by email at contact(at)refundmyticket.net.
« Airline » : means any air carrier that performed or intended to perform the flight subject of the recovery proceedings initiated by CLAIM ASSISTANCE on behalf of the Client.
« Amicable Procedure/Amicable Recovery » : means the actions and negotiations initiated by CLAIM ASSISTANCE with the Airline, in order to reach an amicable agreement and obtain the payment of the Compensation for the benefit of the Client, excluding the use of Mediation or Judicial Proceedings.
« Attorney » : means any lawyer duly registered in any bar of any country or any law firm duly registered.
« Client » : means any person using the Services offered by CLAIM ASSISTANCE on the Website and having accepted these General Terms and Conditions.
« Compensation » : means the payment made by the Airline to the benefit of the Client following an Amicable Settlement, a Mediation or Judicial Proceedings initiated by an Attorney.
« Contract » : means these GTC together with the Power of attorney duly signed by the Client.
« General Terms and Conditions » or « GTC » : means these General Terms and Conditions explaining the rights and obligations of CLAIM ASSISTANCE and its Client within the scope of their contractual relationship, as well as the Terms and Conditions of the Services offered by RefundMyTicket within the scope of European Regulation no. 261/2004.
« Judicial Proceedings » : means the procedure that will be initiated by an Attorney before the competent court in order to obtain the payment of the Compensation by the Airline Company for the benefit of the Client.
« Mediation » : means the procedure involving a mediator, chosen by CLAIM ASSISTANCE, in order to reach a transactional agreement and to obtain payment of the Compensation by the Airline Company for the benefit of the Client.
« Parties » : means CLAIM ASSISTANCE and the Client.
« Power of attorney » means the document whereby the Client authorizes CLAIM ASSISTANCE to act on their behalf in order to claim compensation to the concerned Airline.
« Services » : means any and all Services offered by CLAIM ASSISTANCE on the Website.
« User Account » : means the account opened under the name of the Client following confirmation of his/her online request by email under the conditions set out below.
The GTC apply, without restriction or reserve, to any and all Services offered by CLAIM ASSISTANCE on the Website and to all Clients.
The Clients acknowledge their acceptance of the GTC by checking the box provided when registering their Compensation request on the Website.
Any request implies full and complete acceptance by the Client of the GTC in force on the day of the request.
CLAIM ASSISTANCE has the right to amend the GTC at anytime provided the Client is informed by email of such amendment. Failing to reply within seven (7) days following reception of the informative email, the Client will be deemed to have accepted the amended GTC, which shall then apply to the ongoing Contract.
The GTC have been originally drafted in French and CLAIM ASSISTANCE may provide translation of those in any language on the Website. In case of discrepancy, the French version shall prevail.
The GTC are available on the Website where they can be directly consulted.
If any provision of these GTC is or becomes ineffective, illegal or unenforceable, the validity of the remaining provisions shall not be affected.
The fact that CLAIM ASSISTANCE does not invoke any provision of these GTC at a particular point in time shall not be interpreted as a waiver of the right to invoke the same GTC at a later date.
The purpose of these GTC is to determine the contractual rights and obligations of the Parties in relation to the use of the Services offered on the Website.
CLAIM ASSISTANCE acts as representative on behalf of the Client, in accordance with the provisions of Articles 1984 et seq. of the French Civil Code.
These GTC determine the conditions of use of the Services.
CLAIM ASSISTANCE offers on the Website a service allowing passengers to claim Compensation to Airlines in the event of denied boarding and of cancellation or long delay flights under the conditions set out below.
The Website Services are accessible by the Client 24 hours a day, 7 days a week and all year round, except in the event of voluntary or involuntary interruption, regardless of the cause. In particular, this may involve maintenance. Being by its activity subject to an obligation of means, CLAIM ASSISTANCE cannot be held liable for any physical, material, financial or moral damage caused by the temporary unavailability of the Website.
The Client submits his/her request on the Website by filling a form containing the following information:
In order to confirm submission of the form, the Client shall first accept these GTC by checking the box “I have read and I accept the Terms and Conditions”.
Any Client adding one or more passengers to a request warrants that he/she has been expressly or tacitly authorized to do so by the aforementioned passengers. These passengers will be deemed to have given their agreement and to have been informed of the Compensation procedure initiated by the Client acting in their name and on their behalf. In such cases, the Client shall check a box confirming that he/she has been authorized to act on behalf of the other passengers.
The Client filling the form shall be CLAIM ASSISTANCE’s only contact and shall be considered as the “Client”.
CLAIM ASSISTANCE declines all responsibility for any consequences related to the intervention of a third party not authorised to make the request in the name and on behalf of other passengers.
The Client undertakes to provide accurate, valid, current and true information and is solely responsible for the information provided by him/her in the form.
CLAIM ASSISTANCE will send the Client an email confirming receipt of his request and summarising the essential elements of the request. CLAIM ASSISTANCE is not bound by this email.
The client must confirm his request by clicking on the appropriate button.
After the request has been confirmed, the Client receives a user name and password, which gives him/her access to his/her Personal Area, where he/she will be able to follow up on his/her Claim for Compensation. The Client shall be free to change the password that has been assigned to him/her and shall be solely responsible for creating a sufficiently secure password that is used to access the Site. He/she shall be solely responsible, both for any improper disclosure and for any use that may result therefrom.
The Client undertakes to keep his/her password secret and not to disclose it to a third party; he/she is solely responsible for access to his/her Personal Area.
Following validation of the Client’s request by CLAIM ASSISTANCE, a Power of Attorney will be sent to the Client. The Client must sign this Power of Attorney electronically and will also receive an email indicating the supporting documents required for the processing of his/her claim.
Under the terms of the Power of Attorney, the Client authorises CLAIM ASSISTANCE to :
The Client must electronically sign the Power of Attorney from the link that CLAIM ASSISTANCE will have sent him/her, and must send by email or upload to his/her Personal Area all documents justifying his/her claim for Compensation, namely :
The Contract will only be formed and CLAIM ASSISTANCE will only be committed upon receipt of the Power of Attorney signed by the Client and the requested supporting documents.
On the basis of the information provided by the Client, CLAIM ASSISTANCE, together with the Lawyer of its choice, analyses the claim for Compensation.
CLAIM ASSISTANCE reserves the right to refuse a request made by any Client on the Website without giving any reason. In this case, the Client will not be liable for any costs.
If CLAIM ASSISTANCE agrees to process the Client’s request, a confirmation email will be sent to the email address provided in the request form.
By agreeing to these GTC, the Client guarantees that no amicable or legal debt collection proceedings have been initiated by the Client or any third party.
Following acceptance of the Client’s claim for compensation by CLAIM ASSISTANCE, a letter will be sent to the Airline by any means, in order to request the Compensation due to the Client.
This letter will contain :
If the Airline agrees to, CLAIM ASSISTANCE will collect the Compensation in the name and on behalf of the Client, and CLAIM ASSISTANCE will refund the amount due under the conditions set out below.
At the end of this Amicable Recovery Procedure, the Client’s claim must go through a Mediation procedure. This step is compulsory under French law, since the entry into force of Law n°2019-222 of 23 March 2019, for all disputes under 5000 euros.
The Mediation procedure lasts 60 days. CLAIM ASSISTANCE contacts the mediator simultaneously by email and by registered letter with acknowledgement of receipt. CLAIM ASSISTANCE and the Airline will then discuss and attempt to find an amicable solution to their dispute, under the supervision of the mediator.
The Client will be able to access the content of the exchanges during the Mediation and intervene if he/she deems it necessary. These exchanges will remain confidential, unless the Client and the Airline both agree to lift the confidentiality.
Any agreement concluded during this Mediation will be signed by CLAIM ASSISTANCE, which the Client accepts.
If the Mediation is successful, CLAIM ASSISTANCE will collect the Compensation in the name and on behalf of the Client, and CLAIM ASSISTANCE will pay the Client the amount due to him/her in accordance with the conditions set out below.
Alternatively, if the Mediation fails, CLAIM ASSISTANCE will receive a Certificate of Attempted Mediation, which is an indispensable document for asserting the Client’s rights before the courts. If the Mediation is unsuccessful, the Client will not be charged.
In the event that the request for Compensation is rejected by the Airline and the Mediation fails, or in the absence of a answer, the Client authorises CLAIM ASSISTANCE to forward his/her case to the Lawyer of its choice, who will be responsible for seeking the condemnation of the Airline through legal proceedings, provided the Lawyer considers it appropriate. The Client hereby accepts that all information provided by him/her on the Website and all documents sent to CLAIM ASSISTANCE will be transferred to the Lawyer.
CLAIM ASSISTANCE undertakes to bear all costs associated with the Legal Proceedings in the name and on behalf of the Client, regardless of the outcome of the Legal Proceedings.
CLAIM ASSISTANCE shall bear any costs incurred by the Client as a result of the Legal Proceedings.
It is specified that CLAIM ASSISTANCE carefully selects the Lawyers it chooses to call upon according to their skills, in order to guarantee the best chances of success for the procedures undertaken.
CLAIM ASSISTANCE undertakes to inform the Client by email of the name of the Lawyer in charge of the procedure. A fee agreement will be sent to the Client and must be signed and returned to the Lawyer.
The Client is free to refuse the Lawyer appointed by CLAIM ASSISTANCE and may exercise this right of refusal within forty-eight (48) hours following receipt by email of the name of the Lawyer.
Failure by the Client to reply within this delay will constitute tacit acceptance of the Lawyer chosen by CLAIM ASSISTANCE.
If the Client refuses to accept the appointed Lawyer, CLAIM ASSISTANCE may terminate the CLAIM ASSISTANCE Agreement. In view of the Services provided by CLAIM ASSISTANCE the Amicable Recovery of the Client’s compensation, the Client shall be liable for the Commission set out in Article 5 of these GTC.
The Client is then free to pursue the compensation proceedings with the Lawyer of his/her choice, the costs of which are to be borne by the Client alone. The “no win no fee” guarantee will not be acquired by the Client in such a case.
CLAIM ASSISTANCE shall send an invoice to the Client by email reminding the amIf, at the end of the Amicable Debt Collection Procedure, the Airline agrees to compensate the passenger, the Client authorises CLAIM ASSISTANCE to collect the amount due in his/her name and on his/her behalf.
CLAIM ASSISTANCE undertakes to pay the amount due to the Client within thirty (30) days following the actual recovery, less CLAIM ASSISTANCE’s commission as defined in Article 5 of these GTC, i.e. 18% (incl. VAT) of the Compensation obtained. In the meantime, an invoice will be sent to the Client by e-mail, detailing the sums received and the sums due to CLAIM ASSISTANCE.
The Client hereby acknowledges and agrees that CLAIM ASSISTANCE will have the right to refuse any Compensation from the Airline by any mean other of payment.
The Client undertakes to inform CLAIM ASSISTANCE of any payment received directly from the Airline. In such case, the Client undertakes to pay CLAIM ASSISTANCE the amount of its commission, i.e. 18% (inclu. VAT) of the Compensation, in accordance with Article 5 of these GTC, within thirty (30) days from the collection of the Compensation.
Failing this, a penalty equal to the rate applied by the European Central Bank, increased by 10%, shall apply until actual receipt of the funds on CLAIM ASSISTANCE’s bank account. CLAIM ASSISTANCE may take any measures to recover the sums due in respect of its intervention from the Airline, in accordance with the Power of Attorney previously signed by the Client and without prior notice.
If, at the end of the Mediation procedure, the Airline agrees to compensate the passenger, the Client authorises CLAIM ASSISTANCE to collect the amount due in his/her name and on his/her behalf.
CLAIM ASSISTANCE undertakes to pay the sums due to the client within thirty (30) days following the actual recovery, less CLAIM ASSISTANCE’s commission as defined in Article 5 of these GTC, i.e. 24% (incl. VAT) of the Compensation obtained. In the meantime, an invoice will be sent to the Client by e-mail, detailing the sums received and the sums due to CLAIM ASSISTANCE.
The Client hereby acknowledges and agrees that CLAIM ASSISTANCE will have the right to refuse any Compensation from the Airline by any mean other of payment.
The Client undertakes to inform CLAIM ASSISTANCE of any payment received directly from the Airline. In such case, the Client undertakes to pay CLAIM ASSISTANCE the amount of its commission, i.e. 24% (inclu. VAT) of the Compensation, in accordance with Article 5 of these GTC, within thirty (30) days from the collection of the Compensation.
When Judicial Proceedings have been initiated by a Lawyer, the Compensation due to the Client by a Court order will be paid into a CARPA account and then paid to the Client, after deduction of the Lawyer’s fees as defined in the fee agreement and after deduction of CLAIM ASSISTANCE’s commission as defined in these GTC.
The Client agrees that the full amount of the costs of the proceedings awarded by the judge pursuant to Article 700 of the French Code of Civil Procedure will be retained by the Lawyer in charge of the case.
The Client is responsible for the accuracy of the bank details which he/she will transmit to CLAIM ASSISTANCE or the Lawyer for the payment of the sums due to him/her.
If the Client has made a request for more than one passenger, only one bank account may be registered on the Website. The Compensation will be paid into this bank account and the Client will be solely responsible for the distribution of the sums to the other passengers. The reference of this bank account may be changed by the Client at any time prior to the payment of the Compensation.
CLAIM ASSISTANCE’s commission is based on a percentage of the amount of Compensation received by the Client.
The commission is calculated as follows:
It is specified that the amount of these commissions do not include:
The Client shall bear these costs, which will be deducted by CLAIM ASSISTANCE from the Compensation to be paid to the Client.
The Client agrees that the commissions due to CLAIM ASSISTANCE shall be directly retained from the Compensation received on behalf of the Client in case of Amicable Recovery, Mediation or by the Lawyer in case of Judicial Proceedings.
In case of termination of the Contract by the Client or due to breach of Contract by the Client and whenever CLAIM ASSISTANCE has performed the Services under the Contract, the Client undertakes to compensate CLAIM ASSISTANCE. Such compensation shall amount to:
The commission due to CLAIM ASSISTANCE in such cases shall be paid within eight (8) days following the sending of the termination letter.
In accordance with Article L. 121-21 of the French Consumer Code, the Client has a right to withdraw from the Contract within fourteen (14) days from the day CLAIM ASSISTANCE receives the Power Of Attorney signed by the Client.
Should the Client exercises his/her right of withdrawal, CLAIM ASSISTANCE will be automatically relieved from all of its contractual obligations under the Contract.
To withdraw from the contract, the Client must fill in the withdrawal form attached to these GTC.
CLAIM ASSISTANCE undertakes to carry out its debt recovery mission with prudence, diligence and in a relevant and loyal manner in compliance with the regulations in force.
CLAIM ASSISTANCE acknowledges that it has taken out an insurance policy guaranteeing the Client against the pecuniary consequences of the professional civil liability it may incur due to its liability and that it has a bank account exclusively allocated to receiving the funds collected on behalf of its Clients.
The Client acknowledges that the contractual obligations of CLAIM ASSISTANCE are only obligations of means and that CLAIM ASSISTANCE cannot guarantee the success of the Amicable Recovery Procedure or the Mediation or the Judicial proceedings.
CLAIM ASSISTANCE cannot be held liable for any contingencies that may arise in connection with the Client’s claim for Compensation.
CLAIM ASSISTANCE is obliged to guarantee the protection of the Client’s personal data in accordance with the legal provisions set out in Article 12 hereof.
The Client declares to have legal capacity to enter into this Contract, i.e to have legal majority and not being under any legal protective measure such as guardianship, wardship, legal administration, or to be duly represented.
When the Client is a minor, he/she can be represented by his/her legal representative.
If the Client completes a form in the name and on behalf of a third party, he/she is irrefutably deemed to have received a proxy from the third party to enter into a contract with CLAIM ASSISTANCE. The Client is therefore deemed to represent the persons in whose name and on whose behalf he/she has submitted the claim for compensation and to be the sole contact person for CLAIM ASSISTANCE concerning the execution of the Contract. The Client undertakes to provide all information requested by CLAIM ASSISTANCE and to upload all required documents to the Personal Area provided by CLAIM ASSISTANCE. He/she is solely responsible for forwarding the information received by CLAIM ASSISTANCE or by the Lawyer to the other persons involved in the claim.
The Client undertakes to transmit any documents or information requested by CLAIM ASSISTANCE or by the Lawyer as soon as possible and guarantees that the information transmitted is real, accurate, authentic and not misleading.
As soon as the Client accepts the GTC, the Client undertakes to provide CLAIM ASSISTANCE with a copy of all his/her exchanges with the Airline.
The Client must also notify CLAIM ASSISTANCE of any changes that could positively or negatively affect the Amicable Debt Collection, the Mediation or the Judicial Proceedings, especially : any transaction with the Airline, parallel amicable or judicial action without the express agreement of CLAIM ASSISTANCE, the opening of collective proceedings relating to the claims entrusted within the scope of the Power of Attorney, offers of vouchers or any disputes.
The Client undertakes to inform CLAIM ASSISTANCE of any action taken beforehand to collect his/her debt and refrains from interfering in the recovery procedure by contacting the Airline directly, or by mandating any third party to conduct the recovery.
In general, the Client undertakes to cooperate with CLAIM ASSISTANCE and with the Lawyer in the context of the Amicable Procedure, the Mediation or the Judicial Proceedings.
If the Client wishes to stop the procedure, he undertakes to notify CLAIM ASSISTANCE as soon as possible and to pay the costs set out in Article 5 of these GTC. If Judicial Proceedings have been initiated, the fee agreement concluded with the Lawyer will specify the sums to be reimbursed in the event of discontinuation.
The Contract is concluded for an unlimited period of time and ends when the Compensation paid by the Airline is transferred to the Client by CLAIM ASSISTANCE after deduction of all applicable fees, excluding cases of termination or withdrawal.
CLAIM ASSISTANCE reserves the right to unilaterally terminate the Contract and thus to stop the recovery procedure, without prior notice, in the following situations:
CLAIM ASSISTANCE undertakes to inform the Client of the termination by email with acknowledgement of receipt and to give reasons for the termination. The termination will take effect upon receipt of the email or when this information appears in the Client’s Personal Area. CLAIM ASSISTANCE shall bear all costs incurred up to this point.
The Client may also terminate the Contract unilaterally. In this case, the customer shall be liable for the sums specified in Article 5 of these GTC.
If the Parties disagree as to the decision to be taken in the context of an amicable settlement proposal from the Airline, the Contract may be terminated by the Party in favour of the proposed payment:
If the Client accepts the settlement proposal from the Airline against the advice of CLAIM ASSISTANCE, the Client shall be liable for the costs incurred by CLAIM ASSISTANCE from the time the claim was made until the Client accepts the proposal. The Client shall therefore pay CLAIM ASSISTANCE :
If CLAIM ASSISTANCE accepts the settlement proposal made by the Airline, CLAIM ASSISTANCE will retain 18% (incl. VAT) of the amount of Compensation offered by the Airline.
Termination of the contract is automatic in the following cases:
In such cases of automatic termination, Article 5 of the GTC shall apply.
In the event of the death of the Client, the Power of Attorney is transferred directly to his/her heirs, who may terminate it.
The obligation of CLAIM ASSISTANCE is an obligation of means.
CLAIM ASSISTANCE undertakes to do its utmost to obtain compensation from the different Airlines, but cannot guarantee the outcome of the Amicable Debt Collection, the Mediation or the Judicial Proceedings.
Thus, CLAIM ASSISTANCE will not be held responsible for the refusal of payment of the Compensation by the Airline or for an unfavourable court decision rejecting the request for Compensation.
In general, CLAIM ASSISTANCE cannot be held responsible for delays or failures in Compensation claims submitted to the Airlines.
Consequently, the Client may not claim any Compensation from CLAIM ASSISTANCE.
CLAIM ASSISTANCE shall not be liable for any failure to perform or improper performance of its obligations due either to the fault of the Client, or to the insurmountable and unforeseeable act of a third party to the Contract, or to force majeure.
CLAIM ASSISTANCE cannot be held liable for the use that is made of the Services, for direct or indirect damage caused to the Client or to third parties, nor even for direct or indirect damage caused to the software (software, data, programs, files…) or hardware (hardware, cable, network…) of the Client or third parties.
CLAIM ASSISTANCE cannot be held liable for the unavailability of its Website or its Services as a result of force majeure as defined by the law, nor for unavailability due to external factors beyond the control of CLAIM ASSISTANCE.
CLAIM ASSISTANCE cannot be held liable and no Compensation can be claimed in the event of failure to return, disappearance due to fire, loss or any other cause resulting from a case of force majeure of the documents which have been transferred to CLAIM ASSISTANCE.
Any complaints and/or disputes from the Client against CLAIM ASSISTANCE must be submitted (with an explanation) exclusively by email to contact(at)refundmyticket.net.
In application of the French Data Protection Law of 6 January 1978, the Law of 20 June 2018 on the protection of personal data and Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016 on the protection of individuals with regard to the processing of personal data, the personal information requested from the Client is necessary for the proper processing of the Claim for Compensation and is intended for the Services of CLAIM ASSISTANCE and its partners. It is adequate, relevant and not excessive with regard to the purposes for which it is collected. This information is strictly confidential and is treated in a fair and lawful manner.
The Client hereby consents to the automated processing of the personal data he/she has provided to CLAIM ASSISTANCE.
The Client has the right to access, correct, delete and limit all personal data concerning him/her. This right can be exercised by sending an email to the following address: contact(at)refundmyticket.net.
CLAIM ASSISTANCE keeps all data transmitted for a period not exceeding the time required for the purposes for which they are collected and processed.
The databases through which the company CLAIM ASSISTANCE carries out automated processing of personal data are declared to the CNIL under the number 185767 V 0.
By providing CLAIM ASSISTANCE with his/her personal data, the Client authorises their use as part of this Contract.
In order to guarantee the security of the personal data provided by the Client, the Client must comply with the following security rules recommended by the CNIL:
The Client also authorises the use of personal data for marketing targeting, statistics, and in general for the commercial exploitation of a behaviour.
Clients may oppose the receipt of marketing documents by clicking on the link available at the bottom of the email or by sending an email to the following address: contact(at)refundmyticket.net.
It is also possible for the Client to lodge a complaint with the CNIL in the event of a violation of the protection of his personal data by CLAIM ASSISTANCE.
All elements of the Website, whether visual or audio, including the underlying technology, are protected by intellectual property rights.
CLAIM ASSISTANCE has the exploitation rights to all these elements.
CLAIM ASSISTANCE is therefore the owner of all copyrights relating to mail and copies thereof sent to the Airlines.
CLAIM ASSISTANCE does not hereby transfer any ownership rights to the mail and any other documents sent to the Airlines and to the Parties.
CLAIM ASSISTANCE’s correspondence and all the content of the Website (text, graphics, logos, buttons, images, icons and software components) are its exclusive property.
The Client is strictly prohibited from reproducing, representing or distributing, even partially, any particular element that is an integral part of the Website.
The Client is also obliged not to reproduce or disseminate the paper and electronic mail templates designed by CLAIM ASSISTANCE and sent to the Client during the execution of the Contract.
The Parties agree that this Agreement is subjected to French law.
All disputes arising out of or in connection with the validity, interpretation, performance, non-performance or termination of this Contract shall be submitted to the competent Court, as determined in accordance with the applicable law.
Appendix: Withdrawal form
Please fill in the form below and return it only if you wish to withdraw from the Contract.
To CLAIM ASSISTANCE
19, rue Honoré d’Estienne d’Orves, 93500, Pantin FRANCE
I hereby notify you of my withdrawal from the contract concerning the claim for compensation submitted on your website on ……………………….., confirmed by email on ……………….. and for which a Power of Attorney on behalf of CLAIM ASSISTANCE was signed on …………………………… .
Name of the Client(s):
Address of the Client(s):
Signature of the Client(s) (only in case of withdrawal on paper form):