1. No category

Claim number
(To be filled in by AIG)
NOTIFICATION OF CLAIM – EAR Insurance
POLICY HOLDER
Corporate Number
Policy Number
Company Name
Contact Person
Postal Address
Postal Code and City
Telephone/Mobile
E-mail
I agree to be contaced by e-mail
Any compensation shall be paid to:
Name of Bank
Bank account incl. clearing
Name if recipient of payment is other than policyholder
Is any other insurance affected?
Yes
IBAN Number
Bankgiro
Plusgiro
SWIFT Code
If yes, which company?
What type of insurance?
Company
Claim number
No
Has notification been made to
another insurance company?
Yes
No
INFORMATION APPLICABLE FOR ALL CLAIMS
Country Code (please find the Country codes at the end of this document, appendix 1).
Ericsson Trigram Code (please find the Trigram codes at the end of this document, appendix 2).
Please note that AIG will NOT be in a position to respond to your claim without sufficient information on the Country code and Ericsson trigram code.
It is very important that all information is filled in on the claims form to ensure that your claim is processed in a timely manner.
Place of insurance (street address and municipality)
Block/Plot
Property designation
When did the loss occur? Year/Month/Day and time
Where did the loss occur?
When can the loss be inspected and whom shall the inspector contact?
Telephone Number
Detailed description (by all means continue on a separate sheet of paper) regarding the occurence and extent of the loss
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ADDITIONAL INFORMATION
Do you consider that someone
else is responsible for the loss?
Telephone Number
Yes/Name
No
Has any third party been injured or had their property damaged?
Yes
No
If so, please give a short description of the loss
Has the injured party contributed to the loss?
Is there an insurance covering the same loss with another company?
Yes
No
Policy Number
Sum Insured
If yes, state the Company Name
SPECIFICATION
What is the estimated amount of loss?
Was the incident reported to the police or firebrigade
Yes
No
SIGNATURE
Please note that it is critical that you obtain full details of each claim presented to you by a Ericsson Company. Therefore, when processing the Claim
Form, please ensure that all fields are fully completed so that the relevant information can be transferred into AIG claims management system. Should the
Claim Form submitted to you be incomplete, please request additional information from the Submitter of the Claim Form or otherwise refer the matter
to the AIG producing office.
I herewith certify that the above information is correct, and I am aware of its importance in the case of any legal action.
Place and date
Signature
Clarification of signature
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APPENDIX 1 – COUNTRY CODES
ABWAruba
AFGAfghanistan
AGOAngola
AIAAnguilla
ALA Åland Islands
ALBAlbania
ANDAndorra
ARE United Arab Emirates
ARGArgentina
ARMArmenia
ASM American Samoa
ATAAntarctica
ATF French Southern Territories
ATG Antigua and Barbuda
AUSAustralia
AUTAustria
AZEAzerbaijan
BDIBurundi
BELBelgium
BENBenin
BESBonaire, Sint Eustatius and
Saba
BFA Burkina Faso
BGDBangladesh
BGRBulgaria
BHRBahrain
BHSBahamas
BIH Bosnia and Herzegovina
BLM Saint Barthélemy
BLRBelarus
BLZBelize
BMUBermuda
BOL Bolivia, Plurinational State of
BRABrazil
BRBBarbados
BRN Brunei Darussalam
BTNBhutan
BVT Bouvet Island
BWABotswana
CAF Central African Republic
CANCanada
CCK Cocos (Keeling) Islands
CHESwitzerland
CHLChile
CHNChina
CIV Côte d’Ivoire
CMRCameroon
CODCongo, the Democratic
Republic of the Congo
COGCongo
COK Cook Islands
COLColombia
COMComoros
CPV Cape Verde
CRI Costa Rica
CUBCuba
CUWCuraçao
CXR Christmas Island
CYM Cayman Islands
CYPCyprus
CZE Czech Republic
DEUGermany
DJIDjibouti
DMADominica
DNKDenmark
DOMDominican Republic
DZAAlgeria
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ECUEcuador
EGYEgypt
ERIEritrea
ESH Western Sahara
ESPSpain
ESTEstonia
ETHEthiopia
FINFinland
FJIFiji
FLK Falkland Islands (Malvinas)
FRAFrance
FRO Faroe Islands
FSMFederated States of
Micronesia
GABGabon
GBR United Kingdom
GEOGeorgia
GGYGuernsey
GHAGhana
GIBGibraltar
GINGuinea
GLPGuadeloupe
GMBGambia
GNBGuinea-Bissau
GNQEquatorial Guinea
GRCGreece
GRDGrenada
GRLGreenland
GTMGuatemala
GUF French Guiana
GUMGuam
GUYGuyana
HKG Hong Kong
HMDHeard Island and
McDonald Islands
HNDHonduras
HRVCroatia
HTIHaiti
HUNHungary
IDNIndonesia
IMN Isle of Man
INDIndia
IOTBritish Indian Ocean
Territory
IRLIreland
IRN Iran, Islamic Republic of
IRQIraq
ISLIceland
ISRIsrael
ITAItaly
JAMJamaica
JEYJersey
JORJordan
JPNJapan
KAZKazakhstan
KENKenya
KGZKyrgyzstan
KHMCambodia
KIRKiribati
KNA Saint Kitts and Nevis
KOR Korea, Republic of
KWTKuwait
LAOLao People’s Democratic
Republic
LBNLebanon
LBRLiberia
LBYLibya
LCA Saint Lucia
LIELiechtenstein
LKA Sri Lanka
LSOLesotho
LTULithuania
LUXLuxembourg
LVALatvia
MACMacao
MAF Saint Martin (French part)
MARMorocco
MCOMonaco
MDA Moldova, Republic of
MDGMadagascar
MDVMaldives
MEXMexico
MHL Marshall Islands
MKDMacedonia, the former
Yugoslav Republic of
MLIMali
MLTMalta
MMRMyanmar
MNEMontenegro
MNGMongolia
MNP Northern Mariana Islands
MOZMozambique
MRTMauritania
MSRMontserrat
MTQMartinique
MUSMauritius
MWIMalawi
MYSMalaysia
MYTMayotte
NAMNamibia
NCL New Caledonia
NERNiger
NFK Norfolk Island
NGANigeria
NICNicaragua
NIUNiue
NLDNetherlands
NORNorway
NPLNepal
NRUNauru
NZL New Zealand
OMNOman
PAKPakistan
PANPanama
PCNPitcairn
PERPeru
PHLPhilippines
PLWPalau
PNG Papua New Guinea
POLPoland
PRI Puerto Rico
PRKKorea, Democratic People’s
Republic of
PRTPortugal
PRYParaguay
PSE Palestine, State of
PYF French Polynesia
QATQatar
REURéunion
ROURomania
RUS Russian Federation
RWARwanda
SAU Saudi Arabia
SDNSudan
SENSenegal
SGPSingapore
SGSSouth Georgia and the South
Sandwich Islands
SHNSaint Helena, Ascension and
Tristan da Cunha
SJM Svalbard and Jan Mayen
SLB Solomon Islands
SLE Sierra Leone
SLV El Salvador
SMR San Marino
SOMSomalia
SPM Saint Pierre and Miquelon
SRBSerbia
SSD South Sudan
STP Sao Tome and Principe
SURSuriname
SVKSlovakia
SVNSlovenia
SWESweden
SWZSwaziland
SXM Sint Maarten (Dutch part)
SYCSeychelles
SYR Syrian Arab Republic
TCA Turks and Caicos Islands
TCDChad
TGOTogo
THAThailand
TJKTajikistan
TKLTokelau
TKMTurkmenistan
TLSTimor-Leste
TONTonga
TTO Trinidad and Tobago
TUNTunisia
TURTurkey
TUVTuvalu
TWN Taiwan, Province of China
TZA Tanzania, United Republic of
UGAUganda
UKRUkraine
UMIUnited States Minor Outlying
Islands
URYUruguay
USA United States
UZBUzbekistan
VAT Holy See (Vatican City State)
VCTSaint Vincent and
the Grenadines
VENVenezuela, Bolivarian
Republic of
VGB Virgin Islands, British
VIR Virgin Islands, U.S.
VNM Viet Nam
VUTVanuatu
WLF Wallis and Futuna
WSMSamoa
YEMYemen
ZAF South Africa
ZMBZambia
ZWEZimbabwe
APPENDIX 2 – EAR ERICSSON TRIGRAM CODES
Algeria
Ericsson Algerie S.A.R.L.
EAL
Compania Ericsson S.A.C.I.
CEA
Argentina
Ericsson Australia Pty Ltd.
EPA
Australia
Austria
Ericsson Austria GmbH
SEA
Bangladesh
LM Ericsson Bangladesh Ltd.
EBL
Belgium
Ericsson S.A./N.V.
EBR
Ericsson de Bolivia Telecomunicaciones S.A.
EBB
Bolivia
EBA
Bosnia-HerzegovinaEricsson D.O.O.
Brazil
Ericsson Gestao e Servicios de Telecom Ltda
EDA
Brazil
Ericsson Telecomunicacoes S.A.
EDB
Brunei
Ericsson Communication Solutions Pte. Ltd.
EPP
Ericsson Bulgaria
ETB
Bulgaria
Ericsson Cameroon
CMR
Cameroon
Canada
Belair Networks
EAN
Canada
Ericsson Communications Inc.
EMC
Chile
Ericsson Chile S.A.
CEC
Chongqing Ericsson Communication Co. Ltd.
CHQ
China
Ericsson (China) Communications Co. Ltd.
CBC
China
ChinaEricsson
(Guangdong Shunde) Communication Co. Ltd. EXC
China
Ericsson Inspur Communications Tech. Co. Ltd.
LJC
Ericsson Technology (Guilin) Co. Ltd.
MTC
China
Nanjing Ericsson Panda Communication Company Ltd.
China
ENC
China
Nanjing Ericsson Technology Co. Ltd
CLC
China
Shanghai Ericsson Electronics Co. Ltd.
SEC
Colombia
Ericsson de Colombia S.A.
EDC
Costa Rica
Ericsson de Costa Rica S.A.
ERC
Croatia
Ericsson Nikola Tesla
ETK
Czech Republic Ericsson Czech Rep.
ECZ
Denmark
LM Ericsson A/S
LMD
Ecuador
Ericsson de Ecuador C.A.
TEE
Ericsson Egypt Ltd.
EEL
Egypt
El Salvador
Ericsson El Salvdor S.A. de C.V.
ESV
Estonia
Ericsson Estonia
EEE
Finland
OY LM Ericsson AB
LMF
France
Ericsson France S.A.
ESF
Ericsson Georgia
EGE
Georgia
Germany
Ericsson GmbH
EDD
Greece
Ericsson Hellas S.A.
ETG
Guatemala
Ericsson de Guatemala S.A.
EDG
Honduras
Ericsson de Honduras SA
EHO
Ericsson Ltd.
EHK
Hong Kong
Hungary
Ericsson Telecommunications Ltd.
ETH
Indonesia
Ericsson Indonesia
EID
Ireland
LM Ericsson Ltd.
LMI
Israel
Ericsson Israel
EOI
Ericsson (Italy)
TEI
Italy
Italy
Marconi Sud S.P.A.
MSI
Japan
Nippon Ericsson K.K.
NRJ
Kazakhstan
Ericsson Kazakhstan
EKZ
Kenya
Ericsson Kenya Ltd.
EKL
Ericsson-LG LTD
ELG
Korea
L-G Ericsson Co. Ltd
EKR
Korea
Kuwait
Kuwait Ericsson Telephone Equipment and ServicesKET
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140528 v1
Latvia
Lebanon
Lithuania
Macao
Malaysia
Mexico
Moldova
Morocco
Netherlands
New Zealand
Nigeria
Norway
Oman
Pakistan
Panama
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Romania
Russia
Senegal
Serbia
Singapore
Slovakia
Slovenia
South Africa
Spain
Spain
Sri Lanka
Sweden
Switzerland
Taiwan
Thailand
Thailand
Turkey
UK
UK
UK
Ukraine
Uruguay
USA
USA
USA
Venezuela
Vietnam
Ericsson Latvia SIA
Ericsson Lebanon Communications S.A.R.L.
UAB Ericsson Lietuva
Ericsson Macau
Ericsson (Malaysia) Sdn Bhd
Ericsson Telecom de Mexico
Ericsson Telecommunications SRL Ericsson Maroc SARL
Ericsson Telecommunicatie B.V.
Ericsson Communications Ltd
L M Ericsson (Nigeria) Ltd.
Ericsson A/S
Ericsson Oman LLC
ECP Ericsson Pakistan (PVT) Ltd.
Ericsson de Panama S.A.
Ericsson del Paraguay S.A.
Compania Ericsson Sociedad Anonima
Ericsson Telecommunications Inc.
Ericsson Sp. Z.o.o.
Ericsson Telecomunicacoes LDA
Ericsson Caribbean Inc.
Ericsson Telecommunications Romania S.R.L. Ericsson Corporatia AO
Ericsson Senegal SARL
Ericsson D.O.O. ZA Telecomunikacije
Ericsson Telecommunications Pte Ltd
Ericsson Slovakia SPOL. S.R.O. Ericsson D.O.O.
Ericsson South Africa Ltd.
Ericsson Espana S.A.
Ericsson Network Services S.L.
Ericsson Sri Lanka
Ericsson AB (incl. EBC and ECE)
Ericsson AG
Ericsson Taiwan
Ericsson Thailand
LN Srithai Comm Co.,Ltd
Ericsson (Turkey)
Ericsson Ltd.
Ericsson Ltd.incl. All subsidiaries
Ericsson Television Ltd.
Ericsson Subsidiary Enterprise with
100% foreign investments
Compania Ericsson Uruguay S.A.
Ericsson Holding II Inc
Ericsson Inc.
Ericsson Television Inc.
CIA Anonima Ericsson
Ericsson Vietnam Company Limited Ltd.
ELL
ELC
ELT
EHK
ECM
TEM
EMD
EMO
ETM
ENZ
LMN
ETO
OMN
ECP
EDP
EPY
CEP
ENP
EPO
SEP
EPR
ETR
ECR
SGL
EYU
ENO
SBB
EVN
ESA
EEM
ENI
ESL
EAB
EAS
ERT
ECT
XLG
ENK
ETL
SEL
TTE
UKR
CCU
GEU
EUS
TTU
CEV
ETV
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