Certificate holder ISO 9001

Insurance Claim Notification

Name and Last Name*
Company Name
Position
Phone Number*
E-mail*
Vehicle*
Registration Number*
ID Card Number
Status km*
Date of Insurance Claim*
Time*
Place*
Description*
Police Examination*
Reference Number**
Address of given
Police Station**
Participation in Insurance
Claim as*
Data of a Counterparty:
Name and Last Name of a Driver*
Vehicle*
Registration Number*
Insurance Company*
Liability Insurance Policy Number*
Damage Extent
Sending us your filled form you agree to provide your personal data according to the Act No.101/2000 Code of Law
Write the code: code
* mandatory
** one of such marked entry is mandatory, the other is not
*** obligatory only in case of insurance claim participation as the injured party