On-line claim recording sheet concerning insurances

Your personal data:

Name*

Adress:*

E-mail adress:*

Telephone number

Informations concerning the claim:

Type of insurance:*

type of insurance

Name of the organisation involved by the claim: *

exact name of the organisation

Short description of your claim:*

Short description of your claim

Standpoint of the insurer

Which kind of solution do you find favourable?

	Hozzáad Elvesz Mind Törlés

Choose your solution

Attachment of documents:

Documents

Hozzáadás Töröl

Please attache pictures in JPG or TIFF format, documents in DOC or PDF format only.

You can make our work more efficient with attaching the most important documents concerning the case. (For example report made by the police, insurance policy, mailing concernant the case).
If you would like to send us the above date sheet by snail mail, please print it out end attache the copies of the documents.

It is compulsory to fill in the fields market with” * ”. In case these fields are not filled in or not filled in with the correct data, the fields remaining empty or containing incorrect data shall be marked in red. The form can only be sent if the required corrections are made.

The form can be printed using the browser.

Send claim

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