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Home   >  Loss Adjustment   >  Motor Third Party Liability Insurance   >  MTPLI*/OCTA indemnification application for non-material losses incurred by an individual

Loss Adjustment

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

A A A
Application of the injured party, who has suffered a physical injury in the result of a traffic accident and therefore claims a moral compensation.

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

Criminal investigation has been initiated after the accident

Criminal case has been closed
Criminal investigation is pending
Case is heard by the court

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

Victim’s physical trauma
Victim’s mutilation
Victim’s disability
Death of the provider
Death of the dependent
Death of a spouse
Provider’s 1st disability group
Dependent’s 1st disability group
1st disability group of a spouse
Medical care facility /-ties where medical services were provided in relation to the accident

Accident description

In case a victim passed away

Place of accident Elsewhere

Whether MTPLI / OCTA reimbursement has been claimed from some other insurance agency?

Does not exist Exist
Name of the agency

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
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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
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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!

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