Claims Corporation Network

Submit your survey

Request a survey

Step 1 of 3 - REGISTER

1. Basic information
* Please fill in all of the required fields
Company name (applicant)*
Contact person*
First name Surname
Phone number*
E-mailadres*

2. Claim information
* Please fill in all of the required fields
Country of Accident*
Date of Event*
Date Format: DD slash MM slash YYYY
Time of Event

HH :

MM
Description of Event*
Type of Damage*
Exact location of accident
Current location of vehicle*
Estimate of damage amount

3. Attachments
* Please fill in all of the required fields
Upload photo(s) of damage
Drop files here or

Accepted file types: jpg, png, gif, pdf.
Upload attachments
Drop files here or

Accepted file types: jpg, png, gif, pdf.
I hereby give CCN the authority to handle my claim on my behalf.*
- Yes
- No