Damage form Belgium

Damage form
NL Schadeformulier is in Nederlands beschikbaar (zie bovenaan rechts)
UK Form available in English (language selector in upper right corner)
FR Formulaire disponible en Français (voir en haut à droite)
DE Formular in deutscher Sprache verfügbar (siehe oben rechts)
Information Related to the accident

The fields marked with * are mandatory, however we kindly ask you to fill in as many fields as possible.
Select your insurance company
Other
Accident date

DayMonthYear
Country of accident
Accident location

Street Address or Road Number

Street Address Line 2 (optional)

City

Postal / Zip Code
Please provide a short accident description:

0/1000

Contact details of the policy holder (& driver)

The fields marked with * are mandatory, however we kindly ask you to fill in as many fields as possible.
Name of the Driver

SalutationFirst NameLast Name
Email address of the driver
example@example.com
Name of the policy holder (leave blank if contact details of policy holder = driver)

SalutationFirst NameLast Name
Email address of the policy holder
example@example.com

Type of loss

The fields marked with * are mandatory, however we kindly ask you to fill in as many fields as possible.
Type of damage

Other

Details of the vehicle of the policy holder

The fields marked with * are mandatory, however we kindly ask you to fill in as many fields as possible.
Licence plate number
Example: EW12345
Vehicle make
Model
Does the policy holder have a fully comprehensive insurance package?

Property damage

The fields marked with * are mandatory, however we kindly ask you to fill in as many fields as possible.
What type of property and what is the damage ? (Please provide at the end of this form photos of the damage)

0/100

Details third-party

The fields marked with * are mandatory, however we kindly ask you to fill in as many fields as possible.
Name of the third-party

SalutationFirst NameLast Name
Company (if applicable)
Email of the third-party
example@example.com

Details of the vehicle of the third-party responsible for the accident

The fields marked with * are mandatory, however we kindly ask you to fill in as many fields as possible.
Name of the insurance company
License plate number
Vehicle make
Model
Does the third-party have a fully comprehensive insurance package?

Please upload below all the documents relevant to your claim

PLEASE MAKE SURE THAT EVERY FILE IS NAMED CLEARLY. This will ensure a faster processing of your claim.
Damage form (European accident report form, police report, other)

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Photos

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Estimated cost of damage (e.g., cost estimate, appraisal, repair bill, etc.).

Cancelof
Other documents that might be relevant

Cancelof
Please enter the e-mail address where you want to receive a copy of this form:
example@example.com
If you have any question(s) and need to contact us regarding aspects of this form...

You can contact us by phone: +32 (0) 230 1900 (Monday-Friday 09:00-17:00) or by e-mail: info@vanameyde.be
Should be Empty:

Damage form