Sinistres

Accident Report

Please fill in and we will contact you

^{*
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fields}^{. P}^{lease fill in where marked}

Full name:
*

Address:
*

Post code
*
City:

Telephone:
*
Fax:

E-mail:

Insurer* Policy* number Type of * insurance

Damage cause by:*

Fire             Robbery            Water

Civil liability             Vandalism            Collision

Other

DayMonthYear*
Time:*
Place:*

Description of accident:*

Damage sustained:*

Details of other person involved:*
Name, address, vehicle registration nº Details of insurance company Description of visible damage

Injured persons: Yes     No*

Details of injury:

Witness(es) Yes     No*

Details of witness(es):

Did you inform the police or other authorities?: Yes     No*

Name the authority/police involved:

For further clarification, please contact me by:*

E-mail

Fax

Telephone

Post