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New claim
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New claim
Replacement vehicle / vehicle downtime
Reimbursement policy details
Vehicle data
Claim data /breakdown data
Details of the entity providing the replacement vehicle
Vehicle service data
Attachment – copy of the document (-s)
Claimant (Data of the Insured)
Reimbursement policy details
Policy number
VIN number
Personal ID Number/Taxpayer identification number
Find the policy
Insurance inception date
Insurance expiry date
Vehicle data
Registration number
Make
Model
Claim data /breakdown data
Date of claim occurence
Mileage in KM
Repair start date
Repair completion date
Total cost of the claim
Currency
PLN
EUR
GBP
BGN
HRK
CZK
RON
HUF
Was a replacement car provided for the duration of the repair?
Dane podmiotu udostępniającego pojazd zastępczy
Name
Street
House number
Apartment number
Zip code
City
Telephone
E-mail
Vehicle service data
Vehicle service name
Street
Building number
Apartment number (optional)
Post code
City
Telephone
E-mail
Attachment – copy of the document (-s)
A document confirming the date and time the repair was started and the date and time the repair was completed *
Attach:
A document confirming the scope of the repair, the time-consuming nature of the repair and the immobilization of the Vehicle *
Attach:
Document confirming technical inspections of the vehicle *
Attach:
Other attachments
Attach:
A document confirming the costs of renting a replacement vehicle
Attach:
Replacement vehicle rental agreement
Attach:
Potwierdzenie autoryzacji szkody/Odmowa autoryzacji szkody
Attach:
Person reporting the damage (insured person's details)
Name
Surname
Company name
Street name
Building number
Apartment number (optional)
Post code
City
Telephone
E-mail
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