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Insurance claim due to personal legal liability during travel time

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Policyholder*

Policy No.*

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

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

Insured person*

Personal identification code*

Address*

Post code*

Phone no.*

Fax no.

E-mail*

Event date, time (dd.mm.yyyy)*

Event place*

Insurance event - case description*

Unintentionally caused loss, the amount

Recompense receiver

First name, Last name

Personal identification code

Bank account no.

Attached documents

Max 2 MB

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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*