form - CCN

About Us
Services
- Back
- Claims Corporation Benelux
  - Back
  - Regres & Incasso
News
Country Offices
- Back
- Denmark
- România
- Polska
Partners
Contact

Request a survey
Submit your claim
Login

About Us
Services
- Claims Corporation Benelux
  - Regres & Incasso
News
Country Offices
- Denmark
- România
- Polska
Partners
Contact

It can't be played in your browser. Download

Report your claim

Step 1 of 3 - REGISTER

33%

STEP 1 - REGISTER
1. Insured/policyholder
* Please fill in all of the required fields
Name*
First name Surname
Adress*
Address + house number City Province Zip code Country
Mobile*
E-mailadres*

STEP 2 - SUBMIT YOUR CLAIM
1. Claim information
Kind of claim*
Date of incident*
Date Format: DD slash MM slash YYYY
Date of illness*
Date Format: DD slash MM slash YYYY
Location of incident*
City Country
Location: abroad or home country*
City Country
Upload photo(s) of damage
Drop files here or

Accepted file types: jpg, png, gif, pdf.
Upload photo(s) of medical invoice
Drop files here or

Accepted file types: jpg, png, gif, pdf.
Material damage other than to vehicles A and B
- Yes
- No
Injuries even if slight
- Yes
- No
Other family members ill?
- Yes
- No
Witness(es)
- Yes
- No
Contact details witness(es)
name, address, tel.
2. Driver information
Name*
First name Surname
Date of birth*
Date Format: MM slash DD slash YYYY
Driving licence No.*
Driving license valid until:
Date Format: MM slash DD slash YYYY
Upload photo of driving license (both sides)*
Accepted file types: jpg, png, gif, pdf.
Contact information*
Address + house number City Province Zip code Country
Mobile*
E-mailadres*
2. Description incident
Describe the situation of description
2. Description
Description of current situation
3. Vehicle information
Make, type*
Registration No.*
Country of registration*
Country
Trailer*
- Yes
- No
Trailer - Registration No.
Trailer - Country of registration
Country
4. Situation description
1. Parked / stopped*
- Yes
- No
2. Leaving a parking space / opening a vehicle door*
- Yes
- No
3. Entering a parking space*
- Yes
- No
4. Emerging from a parking space, from private premises, from a track*
- Yes
- No
5. Entering a parking space, private premises, a track*
- Yes
- No
6. Entering a roundabout*
- Yes
- No
7. Circulating a roundabout*
- Yes
- No
8. Striking the rear of the other vehicle in the same line of traffic and travelling in the same direction*
- Yes
- No
9. Going in the same direction but in a different line of traffic*
- Yes
- No
10. Overtaking*
- Yes
- No
11. Turning to the right*
- Yes
- No
12. Turning to the left*
- Yes
- No
13. Reversing*
- Yes
- No
14. Changing to a lane reserved for traffic in the opposite direction*
- Yes
- No
15. Coming from the right (at a junction)*
- Yes
- No
16. Had not observed a priority sign or a red light*
- Yes
- No
17. Sketch of accident when impact occurred on paper and upload picture
Indicate
1. the layout of the road
2. by arrows the direction of the vehicles A, B
3. their position at the time of impact
4. the road signs
5. names of the streets or roads
Drop files here or

Accepted file types: jpg, gif, png, pdf.

STEP 3 - INSURANCE INFORMATION*
* see insurance certificate
Name insurance company*
Policy No.*
Insurance Certificate
Valid from
Date Format: DD slash MM slash YYYY
Valid to
Date Format: DD slash MM slash YYYY
Agency (or bureau, or broker)
E-mailadres
I hereby give CCN the authority to handle my claim on my behalf.*
- Yes
- No

Δ

© Copyright 2016. All Rights Reserved, Claims Corporation Network B.V.