Report an accident

1. Insured person

Mobile phone *

Please enter your mobile phone number. E.g.: 79xxxxxxx.

Telephone private

Please provide a valid phone number. Please use this format: 58 472 40 40

Date of birth *

Please enter the date of birth.

Telephone work

Please provide a valid phone number. Please use this format: 58 472 40 40

2. Bank account

3. Date of accident

Date of accident *

Please specify date of accident.

4. Place of accident

5. Circumstances of the accident

6. Description of injuries

7. Incapacity to work

8. Medical treatment (addresses of doctors, dentists, hospitals, clinics, etc.)

9. If a motor vehicle was involved in the accident

10. Additional information

11. Other insurance