Insurance Claim Form Page 3
ADVERTISEMENT
1
2
3
4Question 15 to be answered only in case the driver was unable to drive the vehicle
15 A
What injury or illness prevented the continuation of the journey
on which date?
Date
(Please enclose statement by physician)
(day - month - year)
B
On what date was the return journey home (in The Netherlands)
commenced?
Date
(day - month - year)
C
What is the amount of the additional travel costs home (in The
Netherlands) from the location the driver was unable to continue?
Amount
€
D
What is the amount of the additional return journey and/or
accommodation costs?
Amount
€
Questions 16-17 to be answered only in case of breakdown of the private motor vehicle and/or trailer
16 A
Registration no. motor vehicle
Registration no.
B
In whose name is the vehicle registered?
Name
C
Make and type of motor vehicle, as well as year of manufacture
Make and model
Year manufactured
D
What is the cause of the damage?
E
What does the damage to the motor vehicle/trailer consist of?
F
Where did this occur?
City
G
On which date and time?
Date
(day - month - year)
Time
(hours-minutes)
H
When did you book the motor vehicle and/or trailer in for repair
Date
(day - month - year)
and at which garage?
Garage
(Please enclose statement from garage manager)
I
Was repair within 2 working days possible?
Yes
No
J
Do you have an international circular letter of credit?
Yes
No
K
Do you have a ‘short-term vehicle insurance policy’?
Yes
No
If yes, with which company?
Company
L
Do you hold a continuous third-party and/or comprehensive
insurance policy?
Yes
No
If yes, with which company?
Company
17 A
Was another party involved and do you deem them liable?
Yes
No
If yes, why?
Name and address of the other party
Name and initials
Address
Zip code
City
B
Is repair possible?
Yes
No
(If no, please enclose statement from garage)
C
Has an official record been compiled?
Yes
No
If yes, by whom and where?
Name and initials
City
D
Is the trailer also insured elsewhere?
Yes
No
If yes, with which company and what is the policy number?
Company
Policy number
General
18
If you have incurred damage or loss as a result of reasons other than above, what is the reason for the additional accommodation/return journey costs?
r
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business