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-
Warning:
Marked items
are obligatory
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Basic data of the accident
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Date:
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Time:
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City:
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Place/Street:
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District:
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Country:
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Description:
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Investigated by the Police
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Seated in:
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under the reference nr.:
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Not investigated by the Police
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Details of the liable party - driver
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Name:
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Surname:
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Nationality:
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Birth date:
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Street:
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Nr.:
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City:
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Postcode:
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District:
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Country:
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Telephone:
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E-mail:
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Driving licence number:
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Details of the Liable party - owner
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The same as the liable party - driver
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Company:
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Ident. number:
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Name:
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Surname:
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Nationality:
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Birth date:
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Street:
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Nr.:
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City:
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Postcode:
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District:
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Country:
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Telephone:
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E-mail:
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Towing vehicle of the liable party (fill in the reg.number or mark one of the options)
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Registration no.:
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Country of the registration:
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Vehicle without reg.plate
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Unidentified vehicle
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Category of the towing vehicle:
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Vehicle make:
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Model of the towing vehicle:
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Green Card Nr.:
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Green Card insurer:
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Valid from:
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Valid to:
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Trailer of the liable party
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Registration no.:
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Country of the registration:
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Vehicle without reg.plate
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Unidentified vehicle
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Make/model of the trailer
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Green Card Nr.:
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Green Card insurer:
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Valid from:
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Valid to:
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Details of the damaged party (obligatory item is either the company name or name surname incl. other items marked *)
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Company:
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Ident. number:
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Name:
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Surname:
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Personal identification number:
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Birth date:
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Nationality:
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Street:
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Nr.:
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City:
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Postcode:
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District:
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Country:
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Telephone:
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E-mail:
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Details of the damage suffered and damaged vehicle
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Damage:
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Personal injury
Material damage
Loss of profit
Others
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Towing vehicle of the damaged party
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Registration no.:
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Country of the registration:
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Vehicle category:
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Vehicle make:
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Model of the towing vehicle:
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Trailer of the damaged party
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Registration no.:
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Country of the registration:
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Make/model of the trailer
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Details of the examination of the damaged vehicle (property)
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Examination made the insurer:
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Reference number of the insurer:
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Another company:
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Details of the sender
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The same as the damaged party
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Company:
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Ident. number:
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Name:
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Surname:
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Personal identification number:
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Birth date:
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Nationality:
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Street:
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Nr.:
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City:
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Postcode:
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District:
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Country:
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Telephone:
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E-mail:
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Further information:
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Enclosures (allowed formats: doc, docx, rtf, xls, xlsx, msg, pdf, jpg, jpeg, gif, png, tiff, tif, bmp, max size of 1 enclosure 5MB)
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Enclosure's category
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Enclosure's file
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Enclosure's category
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Enclosure's file
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Enclosure's category
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Enclosure's file
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Enclosure's category
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Enclosure's file
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Enclosure's category
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Enclosure's file
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- The sender of this announcement acknowledges that Czech Insurers’ Bureau, as the recipient of the above mentioned data, is not responsible for their accuracy!
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