Copy Letter Print 1/3/2023 8:10:19 AM AIG Travel EMEA Ltd

Medical Department - 24 hours

Email: UK.Assistance@aig.com
Telephone: +44-1273-765-339
Fax: +44-203-364-7265

To Miss Mariam Popiashvili RE Miss Mariam Popiashvili

From AIG Travel Medical Assistance Case No AE6200399728

Dear Miss Mariam Popiashvili,

We are pleased to be of assistance to you through this difficult time.    Please allow us to confirm the
information given to you during our initial conversation.   

Our company provides assistance for the travel insurance policy that you have.    In order to make
arrangements go as efficiently as possible, we would like to outline some helpful information.

 We will be providing you with 24—hour medical case management.

 We will refer to your case by your last name and/or by Case Number: AE6200399728.
 If, due to your condition or hospital procedures we are unable to communicate with you
directly, we will communicate with your designee.
 Due to confidentiality of your situation, your designee will be required to identify
him/herself by their name and your case number.
 Our medical staff will monitor your case by a series of scheduled consultations with your
treating physician.    Your treating physician will require your authorization to release your
medical information to us and where required, information regarding benefits and billing
instructions will be sent to your treating physician.

The following must be completed, by you or your appointed representative, and returning    to our
office as soon as possible:

 Part A – Completion of the Patient & Travel Information Form.

 Part B – Your signature consenting for AIG Travel to obtain medical information from 3rd
parties on your behalf and to share your medical records with a named designate.

Documents we recommend should accompany your reply:

 Copy of your airline tickets

 If it is likely your travel plans will be disrupted, please provide a copy of the information page
of your passport and any applicable Visas.
 Any medical reports you have already been provided (such as Discharge Summary or “Not Fit
to Fly” certificates)

We hope that our services will help you and your family members through this difficult time.    For
any questions that you may have, please contact us by Email or at the telephone numbers listed,
referring to your case number AE6200399728.   

Sincerely,
Vicky Neighbour
 AIG Travel EMEA Limited

AIG Travel EMEA Limited provides claims and assistance services on behalf of the insurer. AIG Travel EMEA Limited is registered in England
(company number 1728011) with its registered office at Telecom House, 125 – 135 Preston Road, Brighton, BN1 6AF. AIG Travel EMEA Limited
is referred to as “AIG Travel”. AIG Travel is part of AIG, Inc. If you have queries regarding the processing, including accuracy, of personal
information held by AIG Travel, please contact: ukcustomerrelations@aig.com

AIG Travel EMEA Ltd - Medical Department - 24 hours

Email: UK.Assistance@aig.com
Telephone: +44-1273-765-339
Fax: +44-203-364-7265

Part A:    Patient & travel information form

Re: Miss Mariam Popiashvili Date: 29 Dec 2022
Reference
AE6200399728 Email address: mari.popiashvili5@gmail.com
number:
Policy name: Policy number: E064000215
About you
Your email
Your surname: Popiashvili mari.popiashvili5@gmail.com
address:
Your phone
Your first name: 34647343913
number:
Your date of Your home
23-09-1996
birth: country:

Your GP Phone number:

Your GP address: Fax number:
Email address:

About the doctor who is treating you

Patient number:
Phone number:
Treating doctor
Fax number:
name:
Treating doctor
Email address:
address:

About the facility where you’re being treated

Room or ward
Patient number:
number:
Name of treating
Phone number:
facility:
Treating facility
Fax number:
address:
Email address
About your flights

Outbound flight (not including connections or stopovers):

First flight number Departing airport Departure date/ Last arrival airport Arrival date/time
time
Return flight (not including connections or stopovers):
First flight number Departing airport Departure date/ Last arrival airport Arrival date/time
time
 AIG Travel EMEA Ltd - Medical Department - 24 hours
Email: UK.Assistance@aig.com
Telephone: +44-1273-765-339
Fax: +44-203-364-7265

Your travel and ticket information (only complete if your original travel plans are likely to be
disrupted):
Your passport
Your passport issue date:
number:
Your home .,
Your passport expiry date:
address: ,
,
Your visa number:

Other insurance details:

Insurance provider:
Policy number:
Other travel insurance (credit card or bank account):
Policy number:
Additional insured travellers (only complete if your original travel plans are likely to be disrupted):

Name Relationship to you Date of birth Passport number

 AIG Travel EMEA Ltd - Medical Department - 24 hours
Email: UK.Assistance@aig.com
Telephone: +44-1273-765-339
Fax: +44-203-364-7265

How we use Personal Information

American International Group UK Limited is committed to protecting the privacy of customers, claimants and other business
contacts.

“Personal Information” identifies and relates to you or other individuals (e.g. your partner or other members of your family).
If you provide Personal Information about another individual, you must (unless we agree otherwise) inform the individual
about the content of this notice and our Privacy Policy and obtain their permission (where possible) for sharing of their
Personal Information with us.

The types of Personal Information we may collect and why – Depending on our relationship with you, Personal Information
collected may include: contact information, financial information and account details, credit reference and scoring
information, sensitive information about health or medical conditions (collected with your consent where required by
applicable law) as well as other Personal Information provided by you or that we obtain in connection with our relationship
with you. Personal Information may be used for the following purposes:

 Insurance administration, e.g. communications, claims processing and payment

 Make assessments and decisions about the provision and terms of insurance and settlement of claims
 Assistance and advice on medical and travel matters
 Management of our business operations and IT infrastructure
 Prevention, detection and investigation of crime, e.g. fraud and money laundering
 Establishment and defence of legal rights
 Legal and regulatory compliance (including compliance with laws and regulations outside your country of residence)
 Monitoring and recording of telephone calls for quality, training and security purposes
 Market research and analysis

Sharing of Personal Information - For the above purposes Personal Information may be shared with our group companies
and third parties (such as brokers and other insurance distribution parties, insurers and reinsurers, credit reference agencies,
healthcare professionals and other service providers). If you benefit from another party’s insurance policy or service
agreement with AIG (for example, a policy taken out by your employer), personal Information relating to the administration
of that policy or service may be shared with that other party. Personal Information will be shared with other third parties
(including government authorities) if required by laws or regulations. Personal Information (including details of injuries) may
be recorded on claims registers shared with other insurers. We are required to register all third party claims for compensation
relating to bodily injury to workers’ compensation boards. We may search these registers to prevent, detect and investigate
fraud or to validate your claims history or that of any other person or property likely to be involved in the policy or claim.
Personal Information may be shared with prospective purchasers and purchasers, and transferred upon a sale of our
company or transfer of business assets.

International transfer - Due to the global nature of our business, Personal Information may be transferred to parties located
in other countries (including the United States, China, Mexico Malaysia, Philippines, Bermuda and other countries which may
have a data protection regime which is different to that in your country of residence). When making these transfers, we will
take steps to ensure that your Personal Information is adequately protected and transferred in accordance with the
requirements of data protection law.    Further information about international transfers is set out in our Privacy Policy (see
below).

Security of Personal Information – Appropriate technical and physical security measures are used to keep your Personal
Information safe and secure.    When we provide Personal Information to a third party (including our service providers) or
engage a third party to collect Personal Information on our behalf, the third party will be selected carefully and required to
use appropriate security measures.

Your rights – You have a number of rights under data protection law in connection with our use of Personal Information.
These rights may only apply in certain circumstances and are subject to certain exemptions. These rights may include a right
to access Personal Information, a right to correct inaccurate data, a right to erase data or suspend our use of data.    These
rights may also include a right to transfer your data to another organisation, a right to object to our use of your Personal
Information, a right to request that certain automated decisions we make have human involvement, a right to withdraw
consent and a right to complain to the data protection regulator.      Further information about your rights and how you may
exercise them is set out in full in our Privacy Policy (see below).

Privacy Policy - More details about your rights and how we collect, use and disclose your Personal Information can be found
in our full Privacy Policy at: https://www.aig.co.uk/privacy-policy or you may request a copy by writing to: Data Protection
Officer, AIG Europe Limited, The AIG Building, 58 Fenchurch Street, London EC3M 4AB.or by email at:
dataprotectionofficer.uk@aig.com.
 AIG Travel EMEA Ltd - Medical Department - 24 hours
Email: UK.Assistance@aig.com
Telephone: +44-1273-765-339
Fax: +44-203-364-7265

Part B – Authorization for release of information

Insured/Patient Information:

Name: Miss Mariam Popiashvili Date of Birth: 23-09-1996

Case Number: AE6200399728

This authorisation for use or disclosure of medical information is being requested from you to comply with
privacy regulations, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R.
§ 164.508.    If you authorise AIG Travel Assist i.e. data controller, its affiliates or their agents (collectively “AIG”)
the collection, use and disclosure of your PHI for the purposes described below, please tick the relevant box[es]:

1.
By ticking this box I authorise any physician, health care professional, hospital, clinic, laboratory, pharmacy,
pharmacy benefit manager, medically related facility, any other health care provider/medical source and health
plan to furnish AIG with any and all information with respect to any illness, sickness or injury, medical history,
consultation, prescriptions or treatment and copies of all hospital or medical records relating to or affecting the
condition (s) that gives rise to my claim in order for AIG to provide assistance or adjudicate my claim.

2.
By ticking this box I authorise AIG to furnish my medical records to a designated emergency contact (specified
below as appropriate) to facilitate my care, including but not limited to medical transportation arrangements
Individual authorized to receive medical information: Daytime Telephone Number (include area code):

Street Address: City, State and Zip Code:

3.
By ticking this box I authorise AIG Travel to contact my household insurers, medical insurers, other insurers or
any liable third parties (airlines, cruise companies etc.) regarding contribution to a valid claim.

REVOCATION: You have the right to withdraw each of the above authorisations at any time.    If you want to
withdraw your authorisation please write to:
AIG Travel EMEA Limited
Telecom House, 125 – 135 Preston Road, Brighton, BN1 6AF, United Kingdom
Fax: +44-203-364-7265
Email: UK.Assistance@AIG.com
Disclosure of this medical and travel information is voluntary and you may refuse to sign this Authorisation.
However, failure to provide your Authorisation may interfere with your ability to obtain benefits under the
travel insurance policy.    A copy or facsimile of this document shall be considered as effective and valid as the
original.    You are entitled to a copy of this Authorisation.   
PRINTED NAME OF INDIVIDUAL OR PERSONAL REPRESENTATIVE

SIGNATURE OF INDIVIDUAL OR PERSONAL REPRESENTATIVE DATE

If any of the above authorization is provided by individual representative, the representative warrants that

he/she has authority to sign this form on the basis of:

PLEASE ATTACH PROOF OF YOUR AUTHORITY TO ACT ON BEHALF OF THE INDIVIDUAL