Claimant File Form – www.fgaromania.ro

The undersigned

Last name *

First name *

Fiscal ID *

City *

Street

Street Number

building/apt

County/district

Phone number

Email *

ID Type

ID Serial

ID Number

Issued by

Issuance date ( dd/mm/yyyy )

Representative of (for legal persons/holding a mandate/assignment of debt)

Natural/legal person

Name

Fiscal ID

City

Street

Street Number

Building/apt

County/district

Phone/Fax number

Mandatory insurance contract (MTPL of responsible vehicle)/optional insurance contract (CASCO) for which the request is being made

Insurance company

Contract series

Contract number

Validity of insurance policy starting from ( dd/mm/yyyy )

until ( dd/mm/yyyy )

I request the opening of the claim file following the occurrence of insured event

Other risks

Date of occurrence of insured event (dd/mm/yyyy)

City in which I request the ascertainment of damages

County/sector

Attached files (format pdf, jpg, jpeg, gif, png, tif, bmp, maximum 7 MB per file)

Copy of proxy/mandate/cession

Copy of identity document

Copy of amicable car accident settlement/Report drafted by competent authorities

Copy of insurance contract

* By filling in the form and clicking “Submit”, I agree with processing of personal data for the purpose of opening the claim file

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