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Insurance Recompense Claim

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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)*

Submitter*

Identity number*

Address*

Phone number*

Fax

E-mail*

Date when the loss has occurred (dd.mm.yyyy)*

State reg. No. of motor vehicle*

Make, model

Motor vehicle driver / damages of road traffic accident was stated (name, surname)*

Place of the event (city, street):

Damages before the road traffic accident*

Damages after the road traffic accident*

The accident was reported to the police

Information on other persons involved in the road traffic accident:

1. Make, model of motor vehicle:

State reg. No. of motor vehicle

Driver

Policy No.

2. Make, model of motor vehicle:

State reg. No. of motor vehicle

Driver

Policy No.

If the damaged motor vehicle is not presented simultaneously with submission of this claim, where can it be seen during working hours?

Address, contact person, phone No.

Description of the event*

* Necessarily to fill these fields

Scheme of the event

Event photos (each no larger than 2 MB)

Max 2 MB

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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*