Insurance Claim for Compensation

Please, fill the form. All fields marked with * are required.

Name of the applicant

Location of the traffic accident

Date and time of the traffic accident

Damaged motor vehicle data

Property of

Address of the owner

Telephone

Reg. number

Make/model

Year of manufacturing

Engine No.

Chassis No.

Property damage

Documents

№

Data of the driver of the damaged motor vehicle

Name and address

Driving Licence No.

Issued by

Responsible motor vehicle data

Registration No.

Make/model

Driven by

Property of

Green Card No.

Valid from

SHORT DESCRIPTION OF THE EVENT

Please find attached the following documents

Files in the .pdf, .jpg, .png and formats and size of up to 2MB are allowed.

Bank account

Original document from the competent authorities

Traffic Accident Report

Other

I DECLARE THAT IN CONNECTION WITH THE INSURED EVENT

I have not received sums/compensations from third parties or another insurer for that event.I have not concluded a motor own damage insurance policy with an insurance company for this motor vehicle.I have concluded a motor own damage insurance policy for this motor vehicle

Insurance Company Name

insurance Policy №

Valid from/to

Insurance Premium

I declare that I give my consent for the data which I provide voluntary to the National Bureau of Bulgarian Motor Insurers in connection with this damage and which personal as defined in Art .2 of the Personal Data Protection Act to be processed by the National Bureau of Bulgarian Motor Insurers. I am aware that in case of submitting false data I shall bear responsibility under Art. 313 of the PENAL CODE.

We hereby notify you that in connection with the application of Regulation (EU) 2016/679 on the protection of natural persons with regard to the processing of personal data (GDPR) in force from 25/05/2018, the information provided by you will be used only for processing and settling of insurance claims lodged with the NBBMI in regards to the above mentioned traffic accident.