The undersigned Name/Surname
Residence
proprietor (proprietor representative
)
of the motor vehicle type
, registration no
,
facultative insured with policy no.
issued in
,
acknowledge the insured event:
accident,
theft,
fire,
natural perils,
damaged in parking place,
occured in
, hour
, by
unknown person
proprietor,
other person, which drove the vehicle as
with driving license category
,
no.
, issued by
,
at
The event took place in the following circumstances:
And was notified to the Police station from
which issued the followings documents:
serie
no.
.
from
The damages occurred to the above mentioned vehicle consist
in:
Responsible for the damages occurred is
with residence in
insured for motor third party liability at
With policy no.
.which drove the vehicle registered with no.
In order to evaluate the losses please contact :
phone.
The undersigned, declare on my own responsibility that
the statements from this Notification are real and accurate.
