Submit Claim as Injured Party Please fill in the information below. Details of claimant Last Name of Claimant OR Name of legal entity First Name E-Mail Phone Number Details of Lev Ins insured vehicle Type of Vehicle CarBusTruckTrailerOther License plate no. Name of insurance where vehicle is insured Insurance Policy no. Details of damaged vehicle Type of Vehicle CarBusTruckTrailerOther Vehicle manufacturer Model License plate no. Name of insurance where vehicle is insured Insurance Policy no. Is this vehicle a leasing vehicle? Does this vehicle have KASKO insurance? Details about the accident Country of Accident Place of Accident Date of Accident Time of Accident Description of accident circumstances Questions about the accident Did you contact the 24/7 call center of LEV INS at the moment of the accident? YesNo Did you take pictures at the scene of the acident? YesNo Do you speak or understand the language of the accident place? YesNo Do you believe that you are responsible for the accident? YesNo Was the police at the scene of the accident? YesNo Is there a police report? YesNo Have you been fined in relation to the accident or have criminal proceedings been issued against you? YesNo Was a European Accident Report form filled in? YesNo Were you driving under the influence of alcohol or drugs at the time the accident occurred? YesNo Was the driver of TP vehicle driving under the influence of alcohol or drugs at the accident occurred? YesNo Are there any witnesses of the accident? YesNo If yes - indicate Name / e-mail / phone no. of witnesses How many passengers were in the TP vehicle? Was anyone injured? YesNo If yes - indicate how many people were injured and specify injuries Copyright© Center for Insurance Claims 2020 | Imprint | Data Protection
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