Check for departure:
(notification of an insured ivent)
Third party liability - The injured party
 Items marked with * are required. To the report of an insured event, you can enclose 3 files - a driving license, vehicle registration papers, etc Please, fill in as many information as possible.
 
Information about the incident
*Third party liability :
 *Date of the accident D/M/Y:
 *Time of the accident:
*Place of the accident:

Country: 		*Your email:

*Fleet Manager of your company:
Culprit of the accident
*Name of the owner:

*Address (street, city, ZIP code):

  
*Name of the driver:
 *Address (street, city, ZIP code):
 *Telephone Nr.:
*Driving License Nr. :
 *Group of driving license:
    
*Registration number:
 *Type of car:
    
*Third party lability – Insurer:
selection
or 		*the number of insurance contracts:
  
     
The injured party (the holder / user of the vehicle)
Name of the owner: :

Address (street, city, ZIP code):

   VAT:
*Name of the driver:

 

 Address (street, city, ZIP code):
*Phone Nr.:
*Nr. of Driving License:
 *Group of driving license:
  
*Registration number:
 *Type of car:
 Year:
 *Color
Additional infromation

*Injured person:

Injured person (description):

*Damage to other property (No / Yes - description):

*Description of the accident:
*The extent of damage to his own vehicle:
Place of repair:
   
*The police was called:
 The number of police protocol:
In case the police was not called, enclose a copy of your driving license and send as an enclosure or send it to nehody@allgroup.cz

Upload of a file to the server
Enclosure 1 (max. 1MB) :
Enclosure 2 (max. 1MB) :
Enclosure 3 (max. 1MB) :
In :
Date D/M/Y:06/02/2012

 
* Check for departure::