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Accident insurance recompense claim statement

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Insurance holder*

Policy No.*

Validity term of the policy from (dd.mm.yyyy)*

Validity term of the policy to (dd.mm.yyyy)*

Insurant*

Identity number*

Address*

Post code*

Telephone*

Fax

E-mail*

Date and time when the accident has occurred (dd.mm.yyyy)*

Place when the accident has occurred (city, street)*

Description of the event*

Diagnosis

Medical institution (chronological order):

Is the event reported to the police?

Please specify the police division

Was you under alcoholic intoxication in accident moment?

Insurance beneficiary

First name, Last name

Identity number

Bank account no.ta Nr.

Documents enclosed to the claim

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*