Inquiry regarding the party at fault’s insurer (outside PL)

Enquiry about the perpetrator's liability insurer and its claims representative in the injured party's country.

Refers to damage that occurred in one of the countries Green Card Systemcaused by motor vehicles subject to compulsory registration, where the country of residence of the victim and the country of registration of the offender's vehicle were countries EEA or Switzerland.

Inquiry regarding the party at fault’s insurer (outside PL)

"*" indicates required fields

Step 1 of 2

Name

This field is for validation purposes and should be left unchanged.

NOTES: The form shall include interlocks limiting the possibility of selection of certain data. The form can only be completed correctly if the the correct sequence completing the data. If the form cannot be completed correctly, this means that it is not applicable to the case in question. In such a situation, we ask you to sending a written enquiry to the address: pbuk@pbuk.pl

Providing incorrect data when completing the form may result in an incorrect answer or inability to provide an answer.

Coloured fields red and an asterisk are mandatory to be filled in.

Injury data

Date of event*

Country of event*

Details of the offender

Vehicle registration number*

Vehicle make*

Country of vehicle registration*

Name of insurer

(if known)

Insurance policy number

(if known)

Data of the victim

Country of residence*

Contact details of the applicant

Individual / Company*

Individual

Company

Name*

Company name*

Applicant's case number

Preferred method of response

Preferred contact*

Electronic mail

Traditional mail

Ulica*

House/apartment number*

Miasto*

Kod pocztowy*

E-mail address*

0 z 150 maksymalnej ilości znaków

Telephone number

0 z 20 maksymalnej ilości znaków

Inquiry regarding the party at fault’s insurer (outside PL)

Enquiry about the perpetrator's liability insurer and its claims representative in the injured party's country.

In case of accident

Inquiry regarding the party at fault’s insurer (outside PL)

Injury data

Details of the offender

Data of the victim

Contact details of the applicant

Preferred method of response

Statements

Summary form

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