File a claim

Simply fill in the form below and we will contact you at the time of your choosing in order to work together to file your claim.

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Type of incident *

Car
Home
Other

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Select incident *

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Select incident *

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Mrs.
Mr.

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Surname *

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Name *

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Postal code *

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Policy number

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Description of your claim:

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When did it happen? *

Please check date.

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Error 'stepMismatch'

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I would like to be contacted by: *

Phone
E-mail

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Preferably on *

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Please choose a time:

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Phone *

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E-mail *

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E-mail *

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Protection of personal data *

By sending your enquiry you are consenting to us processing your data for the purpose of responding to your enquiry. In all cases where data processing is based on your consent you have the right to revoke this consent at any time. The revoking of your consent does not affect the legality of the data processing carried out up until the revocation based on your former consent. Further information can be found in our privacy policy privacy policy.

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