Damage form Ominimo
Language
  • English (UK)
  • Nederlands

  • Damage form

  • NL Schadeformulier is in Nederlands beschikbaar 
    UK Form available in English

    To report your damage, you will need the following:

    • Details about the incident
    • Your personal and vehicle information
    • Third-party details (if applicable)
    • Supporting documents such as an accident report or photos

  • Contact details of the policy holder

    The fields marked with * are mandatory, however we kindly ask you to fill in as many fields as possible.
  • Format: 00 - 0000 0000.

  • Information Related to the accident

    The fields marked with * are mandatory, however we kindly ask you to fill in as many fields as possible.
  • Date of incident*
     - -
  • 0/1000
  • Were you the driver of the car?*
  • Format: 00 - 0000 0000.

  • Details third-party

    The fields marked with * are mandatory, however we kindly ask you to fill in as many fields as possible.
  • Was another party involved in the incident?*
  • Do you know who the other party is?*
  • Format: 00 - 0000 0000.
  • Is there a third party vehicle involved?*
  • Is it a Dutch license plate?

  • Personal injuries

  • Was anyone injured?

  • Material damage

    The fields marked with * are mandatory, however we kindly ask you to fill in as many fields as possible.
  • Was there damage to your own vehicle?
  • Was there damage to any other vehicle?
  • Was there any other damage (e.g. railings)?
  • 0/100

  • Other people involved in the accident or who witnessed it

  • Were there any witnesses or others involved?*
  • Is the police involved?*
  • Police involvement:
  • 0/50

  • 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.
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  • https://www.mobielschademelden.nl/getting-started 

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  • Confirmation + Review

  • Please review your submission, if you have any question(s) and need to contact us regarding aspects of this form...

    You can contact us by phone: +31 (70) 4137 231 (Monday-Friday 09:00-17:00) or by e-mail: ominimo.intake@vanameyde.com
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