21 November 2019, Thursday

Notice of Claim Form
For us to process your claim effectively and quickly, please fill out the claim form to best of your knowledge and with correct information.
 
GENERAL INFORMATION
Branch
Agency No
Policy No
Beginning Date
End Date
Name Of Insured
Insurance Amount
Date Of Loss (Damage)
Time Of Loss
Place Of Loss
Cause Of Loss

INFORMATION ON DAMAGED PARTY FOR TRAFFIC RELATED DAMAGES
License Plate No
Brand
Type
Model
DEATH / BODILY INJURY
Name, Last Name
Date Of Birth
Occupation
Place Of Expertise
Phone No
 
VEHICLE INFORMATION
License Plate No
Brand
Type
Model
Estimated Damage

COVERAGE AMOUNT
Building
Articles / Goods
Machinery
Fixed Assets
Glass
Other

INFORMATION ON CLAIMANT
Name, Last Name
Phone No

CONTACT PERSON
Name, Last Name
Phone No

Notes
 
 






PENCEREYİ KAPAT