Road accident claim

Customer data :

Your name or social denomination

Your first name or legal form

your email

Date of accident : //

Plate number of your vehicle :

Plate number of your trailer :

Type of road train:

Your bank account number:

Name and address of the repairer

Circumstances of the accident

Data of driver :


First name

Birth date

Length of the service:

Attachment 1:

Attachment 2:

Attachment 3: