Claim report of Motor Breakdown Insurance

Policy data of Motor Breakdown Insurance

Series and number of the policy

VIN number

Insurance inception date

Insurance expiry date

Vehicle data

Registration number

Make

Model

Vehicle service data

Vehicle service name

Street

House number

Flat number

Post code

City

Telephone

E-mail

Claim data /breakdown data

Date of claim occurence

Mileage in KM

Observed vehicle malfunctions (breakdown symptoms) and their circumstances

Repair cost estimate

Currency

Attachment – copy of the document (-s)

Registration card of the vehicle *

Attach:

Document confirming technical inspections of the vehicle *

Attach:

Repair cost estimate *

Attach:

Other attachments

Attach:

Policy

Attach:

Claimant (Data of the Insured)

Name

Surname

Company name

Street name

House number

Flat number

Post code

City

Telephone

E-mail

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