Tweet
  • Applications
  • Contact information
  • Complaints / Recommendations
  • Sitemap
  • FAQs
  • Pohjola.fi
  • Pohjola.lv
  • Latviski
  • По-русски
  • English
Buy Online!
  • Private person insurance
  • Corporate insurance
  • Loss Adjustment
  • Media
  • About Seesam
Search
Home   >  Loss Adjustment   >  Motor Third Party Liability Insurance   >  MTPLI*/OCTA indemnification application for material losses incurred by an individual

Loss Adjustment

  • Motor Vehicle Insurance
  • Motor Third Party Liability Insurance
  • Accident Statement
  • If the road traffic accident has taken place in a foreign country
  • Property Insurance
  • Travel Insurance
  • Accident Insurance
  • Health insurance

MTPLI*/OCTA indemnification application for material losses incurred by an individual

A A A
Application of the injured party, to whom medical treatment expenses, temporary incapacitation or total work disability have been caused in the result of a traffic accident. If the person injured in the result of the accident is died, the claim is filed by the person, to whom funeral expenses have been caused, or by the person, who wants to make statement of loss of supporter of the family.

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.)*

Victim of the accident

First name, Family name*
Personal code*
Address*
Post code
Phone
E-mail
Accident registered by police
No    Yes
Protocol No

Victim’s role at the moment of an accident

Driver
Passenger
Bicyclist
Walker
Other

Victim’s whereabouts at the moment of an accident

In the indemnity vehicle
In the causal vehicle
At the sidewalk
Elsewhere

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

Kind of loss (-es) incurred by a person

Medical treatment of a victim
Vistims’s short-term disability
Victim’s complete disability
Victim’s death
Burial/Funeral related expenses
Loss of provider
Medical care facility/-ties
Listing of medical services

Other valid insurance contracts related to this person

Does not exist Exist
Insurance agency
Policy No.

Accident description

The indemnification for loss to be reimbursed

Through deposit payment
First name, Family name
Personal code
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
 
Attention
Please wait! Data processing takes place.

Only when a message appears on the screen and a copy of your claim is received in your e-mail box, your claim has been sent successfully.
Attention
Warning!
Claim sending failed! Please try again by pressing the button
"Send it again!"
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!

Back to top
2009 Seesam. All rights reserved.