Customer data :
Your name or social denomination
Your first name or legal form
your email
Date of accident : ---01020304050607080910111213141516171819202122232425262728293031/---010203040506070809101112/---201520162017201820192020 Plate number of your vehicle : Plate number of your trailer :
Type of road train: ---CarVanCurtainsiderRefrigerated truckAuto transporter
Your bank account number:
Name and address of the repairer
Circumstances of the accident
Data of driver :
Name
First name
Birth date ---01020304050607080910111213141516171819202122232425262728293031/---010203040506070809101112/---2015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891987198819861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940
Length of the service: ---1 year2 years3 years4 years5 years6 years7 years8 years9 years10 years> 10 yearstemporary driver
Attachment 1: ---Accident declarationPolice reportsData of the opposing partyEstimatePhotos of the damagesOther
Attachment 2: ---Accident declarationPolice reportsData of the opposing partyEstimatePhotos of the damagesOther
Attachment 3: ---Accident declarationPolice reportsData of the opposing partyEstimatePhotos of the damagesOther
Identifiant :
Mot de passe :
