Power of attorney / Insurance comp. *

Correspondent *

  Sir     Madam  

E-mail adress *

Phone number

INSURED

Intermediary *

  Sir     Madam  

E-mail adress *

Phone number

INSURED

Counterparty (in case of liability)

Initial(s) *

Initial(s)

Insertion

Insertion

Surname *

  Sir     Madam  

Surname

  Sir     Madam  

Damage address

Address

Address

Address addition

Address

Address addition

ZIP code

ZIP code

Residence

Residence

Phone number 1

Phone number 1

Phone number 2

Phone number 2

Contact

Contact

E-mail

Damage address

Address

Address

Address addition

ZIP code

Residence

Damage in favor of

  Make a choice   Fire   Water   Storm   Theft   See short discription

Date of damage

Short discription and comments
(example, cause of damage, damage estimate)

Policy details

Policy number

Ensured interest

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Damage number

Coverage

Policy conditions

Insured amount

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