Request form

Important information:

In an emergency, please contact us immediately by phone or fax.

Tel.: +49 211 27112020

Fax: +49 211 30180527

The information marked with an asterisk (*) is mandatory. GRC Assistance needs it to respond to your request for help. Please fill out the form as completely as possible.

1. Who is calling?

Last name*

(Required)

First name*

(Required)

Company / Organization / Agency

Landline and / or cell phone*

(Required)

E-Mail

Further availability

2. Who is ill / injured?

Last name*

(Required)

First name*

(Required)

Birth name

Age / Birth date*

(Required)

Address in Germany:

Street

Number

ZIP

City or town

Current contact address:

Location*

(Required)

Country where located*

(Required)

3. Where is the ill/injured person already receiving medical treatment?

Name of hospital

Address of hospital, department / ward / room

Name of treating physician*

(Required)

Phone of physician*

(Required)

What language does the physician speak?*

(Required)

Remarks

4. What happened? How can we help you?

Please describe briefly the type of injury/illness and the on-site situation:

5. Who pays for the hospital expenses?

in foreign country

in Germany

6. Do you have an international travel health insurance or are you a member of the German Red Cross?

Last name

First name

(District) Chapter

Membership number

Insurance

Insurance policy number

Information:

This request does not justify an assignment for GRC Assistance.

Send request:

Please check all entries to ensure they are correct.