FSG BrokerApplication form of communicative damage

The following questions should be answered by the knowledge acquired at the date of notification. If you do not know/not sure of the answer or it does not apply to your case, please enter n/a or “not applicable

Contact person:

First name and last name:

Telephone number:

e-mail address:

type of damage – cause:

The damage circumstances:

The date of accidence:

The time of accidence:

Place of damage:

City:

Street and number:

Route:

from:

to:

Road number:

Witnesses:

First name and last name:

Telephone number:

The subject of damage:

mark and model:

Registration number:

The process of accident:

Indicative amount of damage in PLN:

actions taken to prevent the damage increase:

name of the authority and unit notified of damage occurrence:

Data of Insurance contract:

Own data:

Name of insurance company:

Policy number:

Carrier data:

Culprit name:

Culprit address:

Culprit telephone number:

Name of insurance company:

Policy number:

Data for inspection:

Place:

City:

Street and number:

Contact person for inspection – vehicle user:

First name and last name:

Telephone number:

e-mail address:

The damage report is not unequivocal to damage recognition by the insurer. The damage report is used for informational purposes only. After submitting the form our representative is going to contact with you in order to accurately determine the circumstances of damage occurrence and to write down the protocol.

I hereby agree for processing my personal data according to art. 23 of the Act of August 29, 1997 on the Protection of Personal Data (Journal of Laws No. 133, item 883 as amended)