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*
Post code*
Telephone*
Fax
E-mail*
Date and time when the incident has occurred (dd.mm.yyyy)*
Place when the incident has occurred (city, street)*
Description of the damaged property and the accident*
Cause of the loss
Approximate loss extent*
Other insurance policies that could cover the loss (indicate policy type and number as well as insurance company)
Documents enclosed to the claim
Max 5 MB
Max 5 MB
Max 5 MB
Max 5 MB
Max 5 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*
