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.

You are here