Damage form Ominimo

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
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*

DayMonthYear
Time of incident

Hour Minutes
Location of the incident*
Main type of damage*
Description of the incident*

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 policy holder*

SalutationFirst NameLast Name
Email address of the policy holder
example@example.com
Phone number of the policy holder
Please enter a valid phone number.
Ominimo policy number
Licence plate*
Example: EW12345
Were you the driver of the car?*

YesNo
Name of the driver

SalutationFirst nameLast name
Email address of the driver
example@example.com
Phone number of the driver
Please enter a valid phone number.

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?

YesNo
Was there damage to any other vehicle?

YesNo
Was there any other damage (e.g. railings)?

YesNo
What is the damage ? (Please provide at the end of this form photos of the damage)

0/100

Other people involved in the accident or who witnessed it
Were there any witnesses or others involved?*

YesNo
Is the police involved?*

YesNo
Police involvement:

Not present, accident reportedPresent after accidentPresent, no report drawn upPresent, report drawn up
Police report reference
Example:PL1234-2025123456
Name of the police station

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.
Accident report form (European accident report form, police report, other)

Cancelof
Photos of the damage

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

Cancelof
Other relevant documents

Cancelof

Confirmation + Review
Confirmation*

I confirm that the details I’ve entered are correct and truthful.
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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Damage form