Accident claim notice

First name of the person reporting *

Last name of the person reporting *

Personal ID code *

E-mail address *

Mobile number *

The person reporting is the injured person *

Yes No

Policy number or the name of the policyholder *

Date when event occurred *

Time of the event

City or village *

Street *

House number or farm name

Apartment number

What has happened?*

Please specify *

The accident occured *

During competitive sports training/competition During amateur sports. Select if you do not compete in this sport

The result of an accident*

Please specify *

Event description * Describe, in detail, the reasons, events and consequences of the insured event

When did the insured person visit a doctor after the accident

Name of the medical institution

Did insured person take a sick leave after the accident? *

Yes No Don't know

Description of the injury or damage *

Was the incident reported to the police? *

Yes No Don’t know

Was the insured person under the influence of alcohol or drugs at the time of the accident? *

Yes No Don’t know

I request an indemnity for the incurred damages *

Yes No

Name of beneficiary

Bank account number

* 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.

Käitumine kahjujuhtumi korral

Details of the person reporting the event

Injured person

Details of the event

File upload (total maximum 30Mb)

Indemnity

ERGO Life insurance+