| maatschappij |
______________________ |
polisnummer |
______________________ |
| schadedatum |
______________________ |
schadenummer |
______________________ |
| |
|
|
|
| Opdrachtgever |
|
|
|
| naam |
______________________ |
! |
|
| emailadres |
______________________ |
! |
|
| |
|
|
|
| |
verzekerde |
tegenpartij |
reparateur |
| naam |
______________________ |
______________________ |
______________________ |
| adres |
______________________ |
______________________ |
______________________ |
| postcode |
______________________ |
______________________ |
______________________ |
| woonplaats |
______________________ |
______________________ |
______________________ |
| telefoon |
______________________ |
______________________ |
______________________ |
| gsm |
______________________ |
______________________ |
______________________ |
| |
|
|
|
object
aanvinken: |
[ ] personenauto
[ ] landbouw
|
[ ] (brom)fiets
[ ] zwaar materieel
|
[ ] motorfiets
[ ] overig:________________ |
| merk |
______________________ |
plaats
schade |
______________________ |
| type |
______________________ |
schatting
schade |
______________________ |
| kenteken ! |
______________________ |
expertise
datum |
______________________ |
| chassisnummer |
______________________ |
reeds
bij reparateur |
ja
/ nee |
| bouwjaar |
______________________ |
totaal
verlies |
ja
/ nee |
| |
|
|
|
| soort
schade: ! |
[ ] aanrijding
[ ] WBF
[ ] brand |
[ ] aanrijding dieren
[ ] ruitschade
[ ] meerdere schades |
[ ] inbraak/diefstal
[ ] vandalisme
[ ] storm |
| |
overig:_______________ |
|
| verzekerde
som |
______________________ |
incl. BTW/excl.
BTW |
|
| Dekking ! |
[ ] WA [ ] plus [ ] casco [ ] RB |
|
| tussenpersoon |
______________________ |
correspondent |
______________________ |
| faxnummer |
______________________ |
telefoon |
______________________ |
| opmerkingen: |
|
|
|
