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Home   >  Loss Adjustment   >  Motor Third Party Liability Insurance   >  MTPLI*/OCTA indemnification application for loss of the indemnitees property

Loss Adjustment

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MTPLI*/OCTA indemnification application for loss of the indemnitees property

A A A
application of the aggrieved party, whose bicycle, perambulator, mobile phone, helmet or other personal effects having been in the vehicle of the aggrieved person or elsewhere (clothes, footwear (motor-cyclist’s clothes and outfit) etc.) has suffered damage in the result of a traffic accident.

Applicant

First name, Family name*
Personal code*
Address*
Post code
Phone*
E-mail
Accident date, time (dd.mm.yyyy)*
Accident place (city, rural district/parish, street, house No.)*

Owner /User of the damaged object:

First name Family name / Name of the agency*
Personal code / VAT Reg. No*
Address*
Post code
Phone
E-mail
Accident registered by police
No    Yes
Protocol No

Loss of the property as the result of the accident

The damaged property was located at
At the indemnitee’s vehicle ( trailer)
At the accident causal agent’s vehicle (trailer)
In the building, at the construction, or elsewhere (to provide the place, address)

Other locations

The property damaged as the result of the accident

No. List of the indemnitee’s property damaged as the result of the accident Date property obtained Value of property Approximate amount of loss

If the damaged property cannot be presented at any of the customer service offices of AAS "Seesam Latvija" (service offices),please specify the location where it might be inspected during working hours

Inspection site of the damaged property (address, phone, contact person)
Other valid insurance contracts related to the object
Does not exist Exist
Insurance agency
Policy No.

Info about the accident causal vehicle

Insurance agency
MTPLI / OCTA Policy series, No.
Vehicle make, model
State reg. No.
Whether the vehicle driver was under the influence of alcohol?
Yes    No    I dont now
Whether the vehicle left the site of the accident?
Yes    No    I dont now
Accident description

The indemnification for loss to be reimbursed

Through deposit payment**
Name of the agency
Through deposit payment***
First name, Family name / Name of the agency
Personal code / VAT Reg. No.
Name of the Bank
Account number (21 symbols)

Documents attached to the application

Max 500 Kb
Max 500 Kb
Max 500 Kb
Max 500 Kb
Max 500 Kb
 
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With this I undertake to provide all the information at my disposal regarding the mentioned event, as well as co-operate to obtain additional information necessary for reviewing this insurance claim.
If the information regarding the conditions of the event provided by me is delusive or false, or if the orders of the insurer will not be followed, the insurance indemnity will be decreased or rejected.
I certify that the information provided is true*

*Fill fields, which is marked with asterisk!

** In case the applicant acts under the Power of Attorney, the POA must be attached to the application

***In the case when the property is leased – specify the bank details of the leaseholder

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