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Home   >  Loss Adjustment   >  Motor Third Party Liability Insurance   >  MTPLI*/OCTA indemnification application for damages to the vehicle or its loss

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MTPLI*/OCTA indemnification application for damages to the vehicle or its loss

A A A
Application of the aggrieved party, whose property (gate, fence, building facade, barriers, traffic lights, lighting poles, traffic signs, 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

Losses to the object as the result of the accident

List ing, description and approximate amount of loss of the object
Inspection site of the object (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

Accident description and layout

The indemnification for loss to be reimbursed

Through payment for the repair services
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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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.
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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

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