Accident Insurance Claim Report

Report insurance events

Notifier

Name

Surname

Title before

Title after

Contact phone

Are you reporting the incident for yourself or someone else?

for myself for another

What is the relationship to the insured / injured person

Sales Representative Number

For company

In what relationship?

Company name

Name of insurance company

In what relationship?

Contract

Insured contract number

Insurance

Cause

Event

Date of event

Event time

State of origin of the event

Place of origin of the event

Data of the insured (for which you are announcing)

NIN / date of birth

Name

Surname

Title before

Title after

Preferred method of communication

electronic communication postal communication

Contact e-mail

Contact phone

I don't know the contact phone

State

Zip code

Village

Street

Descriptive/indicative

Legal representative / guardian of the insured child (for which you are announcing)

Same as " Notifier "?

YES NO

NIN / date of birth

Name

Surname

Title before

Title after

Contact e-mail

Contact phone

State

Zip code

Village

Street

Descriptive/indicative

Event

Date and time the event occurred:

State of the event:

Place of origin of the event:

Event description - Accident insurance - cause of the accident

Detailed event description

Diagnosis

Which part of the body was injured?

Was this part of the body injured before the accident?

YES NO

When and where has the treatment been in the past?

Is the date of the first treatment the same as the date of the event?

YES NO

Date of first treatment

Address of first treatment

Was there subsequent treatment at the site of the first treatment?

YES NO

Where did the follow-up treatment take place? (Addresses of all medical facilities and names of wards or addresses of surgeries and names of doctors)

Is the insured person an athlete?

YES NO

In what sport?

Name of the sports club

At what level?

Was there an accident under the influence of alcohol or other addictive substances?

YES NO

Was there an accident through someone else's fault?

YES NO

Who?

Did you have an accident in a car accident?

YES NO

File no. / Make / name and address of the relevant police department

Was the accident investigated by the police?

YES NO

File no. / Make / name and address of the relevant police department

Is the insured person insured with other commercial insurance companies?

YES NO

Indicate the names of insurance companies

Communication with the assistance service

YES NO

Is the insurance indemnity from the Accident Insurance bound?

YES NO

Indicate the name of the entity in whose favor the encumbrance is carried out

Claiming the Daily Indemnity Insurance for the period of necessary treatment of the accident

Claiming from insurance against bodily injury caused by an accident Period of necessary treatment

Claim from Hospitalization Insurance as a result of an accident

Where did the hospitalization take place?

Same as first treatment Elsewhere

Medical devices

Has the hospitalization already been completed?

YES NO

Hospitalization from

Hospitalization to

Claim from Invalidity Insurance as a result of an accident

Claiming insurance against permanent consequences by accident

Date of termination of injury treatment

What lasting consequences did the injury leave?

Date of establishment of health status

I don't know

Claiming Death Accident Insurance

Is the date of death the same as the date of the event?

YES NO

Date of death

Name and address of the insured person's last general practitioner?

Name, address and telephone number of the notary authorized to carry out the acts of succession

Did the insured die in a motor vehicle?

YES NO

Did the police investigate the accident?

YES NO

File no. / Make / name and address of the relevant police department

Reason

Authorized person

Title before

Name

Surname

Title after

Street

Descriptive/indicative

Village

Zip code

State

NIN / ID

Contact phone

Contact e-mail

Claiming death from accident in a motor vehicle

Method of payment and insertion of documents

to account voucher

Is this a domestic account?

YES NO

NOTIFICATION:
The bank account number must always be confirmed by an entitled person and must be attached to other event reporting documents, using one of the following options:

A scanned or photographed account number, or an account number written on paper (not a bank card) with the number of the insurance policy, the name of the entitled person with his/her handwritten signature and the date of signature

An employee of Pojišťovna VZP, a.s. sale point will verify in writing that the submitted account number belongs to the entitled person (according to his/her identification card, such as a driving licence, a passport etc.), that there is a signature, a date of signature, the legible name of the sale point employee who verified the account number and this document can be attached to the reporting documents or it can be sent by email to oznameni.udalosti@pvzp.cz together with the number of the report, the number of the claim or the insurance policy.

This will speed up the claim settlement process. In case of failure to provide documentation, a loss adjuster will send a request in writing.

Account prefix

Account number

Bank code

Account holder

Currency

IBAN

SWIFT

Bank account number (scan or photo) Select document

Is she the same as the insured?

YES NO

NIN / ID

Name

Surname

Title before

Title after

State

Zip code

Village

Street

Descriptive/indicative

Contact person

It is the same as

insured authorized person legal representative

NIN / date of birth

Name

Surname

Title before

Title after

Preferred method of communication

electronic communication postal communication

E-mail

Contact phone

I don't know the contact phone

State

Zip code

Village

Street

Descriptive/indicative

Loading documents

NOTICE on restrictions on loading documents
Embedded attachments larger than 25 MB in total may not be transferred correctly.
Documents can also be sent via the e-mail address oznameni.udalosti@pvzp.cz or to the address of Pojišťovna VZP, a.s. with the event number or report number.

Attach to the report or please send us these documents as soon as possible to expedite the liquidation investigation

A maximum of 20 files can be uploaded

25 MB LIMIT FOR UPLOAD FILES EXCEEDED, REPORTING CANNOT BE SENT

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