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 Name and bank account number of the receiver of compensation * 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. Your claim report is sent to ERGO claims' processing department.The notice will be forwarded to the claims handler. We hereby inform you that the time required for making decision is up to 10 working days following the receipt of all necessary documents and information. If necessary, we will contact you before making a decision. In case of additional questions please send email to address email@example.com. There was an error during data sending.We are sorry. There was an error during data transfer. Please send your request directly to the email firstname.lastname@example.org.