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Claim report of Motor Breakdown Insurance
Policy data of Motor Breakdown Insurance
Vehicle data
Vehicle service data
Claim data /breakdown data
Attachment – copy of the document (-s)
Claimant (Data of the Insured)
Policy data of Motor Breakdown Insurance
Series and number of the policy
VIN number
Find the policy
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
PLN
EUR
GBP
BGN
HRK
CZK
RON
HUF
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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