Auto Claim

Insured

Nature of the incident

Date of the accident

Time of the accident

Place of the accident

Policy number

Name of the damaged equipment or animal

Name and surname

Profession

Phone

Adress

Vehicle

Vehicle brand

Vehicle type

License plate number

Vehicle usage

Insurance company

Name of the insurance company

Driver

Was the insured person driving the vehicle at the time of the accident ?

Yes

Date of birth of the driver

Category of driver's license

Driver's license number

Date of issue of the driving license

Validity Date of the driving license

Date of issue of the last technical visit

The validity date of the last technical visit

Driver's license number

Have you caused damage to a third party ?

Yes

Use of the vehicle at the time of the accident

Exact location of the Vehicule

Circumstances of the accident

Détails of the accident

Name of the authority issuing the report

Do you want to receive a claim declaration certificate? ?

Yes

Are there any witnesses ?

Yes

Bodily Injury

Were there any deaths in the insured's vehicle ?

Yes

Were there any injuries in the vehicle of the insured ?

Yes

Property damage

Bodily Injury

Are there any deaths outside the opponent's vehicle ?

Yes

Were there any injuries outside the opponent's vehicle ?

Yes

Property damage

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