Corporate insurance claim notice

Notifier details

Policyholder

Name

Registry code

Notifier details

First name

Last name

Country of residence

Personal ID code

Personal ID code/ date of birth

Phone number

Loss event

Policy / Certificate Number

Type of damage

Information about the event that caused the damage

Date

Time

Country

Address

Accuracy of location

Description of the event that caused the damage

0/1000

Notification of incident

Who has been notified of the incident?

Notification Date

Contact details of the notified person or institution

0/500

Incident witnesses

Does the incident have witnesses?

Names and contact details of witnesses

0/500

Damage caused

Description of damage caused

0/1000

Estimated amount of loss

Please describe your unlawful conduct

0/1000

Do you plead guilty to causing the damage?

Please justify your position, including any objections.

0/1000

Date of submission of the claim for damages

Claim amount

In which format is the claim submitted?

Claimant

Name

Country of residence

Personal identification code / registry code

E-mail

Phone number

Are you in any way related to the claimant?

Please describe your relation

Do you agree with the claim made?

To what extent do you disagree, and on what grounds?

Compensation

I apply for compensation for the damage suffered

Yes

Beneficiary

Account number of the beneficiary

Additional information and confirmations

Additional information

0/1000

I confirm the accuracy of the above data and agree to the processing of my personal data by LHV Kindlustus in accordance with the principles of LHV customer data processing.

I know that if I knowingly submit wrong data, then insurer has the right to decrease compensation or refuse to pay compensation completely.

I agree that insurer has the right to request additional information concerning the claim from persons that possess it.

Corporate insurance claim notice

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