Fill in the details of the person who was driving the vehicle at the time of the accident.
Is this driver the usual driver?
Number on which you can be reached during the day
You will receive an e-mail confirmation of this claim at this address
Damage to your vehicle:
Was an official report made:
(if known)
Did you undergo an alcohol test:
Your result:
Include a scan or photo of of the European accident statement form (front and rear). Include any other photos.
(up to 5 photos max.)
(up to 5 files max.)
Indicate the damage to your vehicle on the image below