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