PBUK - Polskie Biuro Ubezpieczycieli Komunikacyjnych - Zapytanie o ubezpieczyciela sprawcy szkody

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Procedure in case of accident

Enquiry concerning insurer of accident maker

Enquiry concerning insurer of person responsible for accident and his claims representative in country of injured party

Applicable in case of loss or injury caused in a country of the Green Card System after 1st May, 2004, if both the injured party and the person responsible are citizens of an European Economic Area country or Switzerland.

In case when a claimant lives in poland and the accident takes place in the territory of poland this form does not applied.

The boxes marked with a red are obligatory..

Details of loss:

Date of occurrence:

Place of occurrence:

Country of occurrence:

Details of person responsible:

Registration number of vehicle:

Make of vehicle:

Country of origin of vehicle:

Name of insurer:

Number of insurance policy:

Details of injured party:

Mailing address

Given name and surname:

Make of vehicle:

Registration number of vehicle:

DECLARATIONS

I declare that I am the person injured in the above-mentioned occurrence (or an attorney of the injured person). The ticking-off of this declaration is a precondition of the dispatch of the form.

I agree to the processing of my personal data by the Polish Motor Insurers' Bureau, in accordance with the Protection of Personal Data Act of 29th August, 1997 (Journal of Law No. 133, item 883). I declare that I have been informed that the statement of my personal data is of a voluntary nature and that I am entitled to inspect as well as to correct them.
The ticking-off of this declaration of agreement is a precondition of the dispatch of the form.

(if known)

Street:

Apartment number:

Mailing code:

City / town:

Country:

E-mail address:

Phone number:

Fax number:

Thank you!

Your enquiry has been sent

Details of loss:

Date of occurrence:

Place of occurrence:

Country of occurrence:

Details of person responsible:

Registration number of vehicle:

Make of vehicle:

Country of origin of vehicle:

Name of insurer:

Number of insurance policy:

Details of injured party:

Mailing address

Given name and surname:

Make of vehicle:

Registration number of vehicle:

Street:

Apartment number:

Mailing code:

City / town:

Country:

E-mail address:

Phone number:

Fax number:

Details of loss:

the enquiry dispatch date

10-08-01 02:35:18

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