DETAILS ABOUT THE APPLICANT OF THE INSURED EVENT

PERSONAL NO. /EGN/

NAME AND SURNAME

PHONE

E-MAIL

DISTRICT

CITY

IN THE CAPACITY OF

OTHER

DRIVER DATA

THE SAME AS THE APPLICANT

PERSONAL NO. /EGN/

NAME

SURNAME

EVENT DATA

DATE

DISTRICT

CITY

ADDRESS

PLACE

GUILTY PARTY

DESCRIPTION OF THE INSURED EVENT

WAYS OF DETERMINING THE INSURANCE INDEMNITY

COMPENSATION

DOCUMENTS AND PHOTOS

SEND

I am informed that the personal data provided by me are processed by Netins Insurance Brokers