English claim form for Belgium

In order to have your claims notification handled, you should take the following steps, within 2 weeks after the date of burglary/damage :

1. Fill out completely the above claim form, including the appendices;
2. Print and/or export the claim form first before clicking on 'Submit Survey';
3. Approve the claim form again or fill out the missing required data fields;

We can only accept your claim if we receive all the necessary documents within 1 month after the burglary/damage.

English Claim Form for Belgium

Filiale leasing

Name *

Contract number *

Surname

First name *

Surname *

Company name *

Adress *

Postal code *

Town *

Country *

Telephone

Fax

E-mail *

Comments

Description of accident/damage & location *

Date *

Month

Day

Year

Time *

Hour

Minute

Cause *

Do you have an other insurance? *

Appendicies

IIn case of burglary *

In case of damage

Please add the attachments here

Files must be less than 2 MB.
Allowed file types: gif jpg png txt rtf html pdf doc docx odt ppt pptx odp xls xlsx ods xml rar zip.

English claim form for Belgium

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