General claim notice

Contact data

Name and personal code *

E-mail *

Phone number *

Insurance case

Damaged object and/or injured persons *Indicate make, model and registration plate for vehicle(s), or description of other objects, and name and personal identification code for persons

Policy number

Location where event occurred *

Date when event occurred*

Event description *Describe how the event occurred and what caused the loss event.

Description of the damage or loss and the expenses caused by the event *

File upload (total maximum 30Mb)

File upload Here you can add documentation that is associated with the case. For example, pictures, price offer, traffic accident report, plane tickets, expense documents, medical documentation, etc

– Remove file

+ Add more files

Payment of compensation

I request the compensation of damages *

Yes No

* I hereby confirm that all data above is right and complete. I know that if I knowingly submit wrong data, then insurer has the right to decrease compensation or refuse to pay compensation completely. I agree that insurer has the right to request additional information concerning the claim from persons that possess it.

General claim notice

Contact data

Insurance case

File upload (total maximum 30Mb)

Payment of compensation

ERGO Life insurance+