FSG BrokerApplication form of property 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.

Data of the person who is reporting the damage:

The damage circumstances:

Locality:

Witnesses:

Data of Insurance contract:

Own data:

Culprit data:

Data for inspection:

Place:

Contact person for inspection:

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.