Please correct the errors in the form below and then click again on the ‘Submit claim’ button.

Submit claim

1

Vehicle

2

Driver

Fill in the details of the person who was driving the vehicle at the time of the accident.

Number on which you can be reached during the day

3

Damage

(Indicate location again)

(if known)

(if known)

(if known)

4

Additional information

(if known)

5

Accident statement

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