Personal Data

First Name*:

Family Name*:

Email address*:

Phone number*:

Plate #*:

Plate Code* :

Preferred way of communication:

Accident Details

Accident Date*:

Accident Time*:

Accident Location*:


Bodily Injuries:

Accident Description*:

Upload Photos

Driver's driving license (front side)*:

Driver's driving license (back side)*:

Car Registration ID (front side)*:

Car Registration ID (back side)*:

Car Damages

Enter Front Accident Locations*:

Enter Front Accident Image:

Enter Back Accident Locations*:

Enter Back Accident Image

Enter Left Accident Locations*:

Enter Left Accident Image

Enter Right Accident Locations*:

Enter Right Accident Image

Do you have any mechanical damage?

Survey & Reparation

What type of insurance you have?*

AMANA Network of Workshops* :

A Workshop of your choice:

Amana Insurance