Vanbreda Risk & Benefits - VanbredaConnect

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Vehicle

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Registration number:

Make:

Model:

Driver

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

Is this driver the usual driver?

yes no

Surname:

First name:

Telephone number:

Number on which you can be reached during the day

E-mail address:

You will receive an e-mail confirmation of this claim at this address

Damage

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Place damage occurred:

Date damage occurred:

Damage to your vehicle:

yes no (Indicate location again)

Repairer(s):

(if known)

Was an official report made:

yes no

Reporting authority:

(if known)

Report number:

(if known)

Did you undergo an alcohol test:

no yes refused

Your result:

safe alarm positive unknown

Additional information

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Circumstances:

Reference number:

(if known)

Accident statement

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Include a scan or photo of of the European accident statement form (front and rear). Include any other photos.

Accident statement (front):

Select file

Accident statement (rear):

Select file

Photo:

Select file

(up to 5 photos max.)

Others:

Select file

(up to 5 files max.)

Comments:

Submit claim

Vehicle

Driver

Damage

Additional information

Accident statement