Make a Claim

Personal Data

First Name*:

Family Name*:

Email address*:

Phone number*:

Plate #*:

Plate Code* :

Preferred way of communication:

by Phone call

by e-mail

Accident Details

Accident Date*:

Accident Time*:

Accident Location*:

Expert:

Yes

Bodily Injuries:

Yes

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?

Yes

Survey & Reparation

What type of insurance you have?*

AMANA Network of Workshops* :

A Workshop of your choice:

I understand that the information in this declaration is on my own responsibility and does not obligate AMANA Insurance s.a.l. in any way. This is a clear and precise info. Before reparation proceeding , I have to make the necessary survey at AMANA or one of the garages mentioned hereunder.