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Policy number

The date of occurrence of the insurance event

Type of insurance claim

Injury treatment

Disability

Permanent disability

Hospitalization

Serious illness

Death

Incapacity

Diagnosis

Who is covered by the insurance event?

Surname

Name

Personal identification number

Address

E-mail

Cell phone

Who reports the insured event

Insured Legal representative Other

If the Insured is reporting, there is no need to fill in the information below

Surname

Name

Birthdate

Address

E-mail

Cell phone

Attachments

Please attach these documents

Medical report from the 1st treatment, medical reports from the course of treatment
Medical reports from the course of treatment, including a medical report when the disease was first diagnosed, a medical examiner's report on the declaration of invalidity, a decision indicating the date of declaration of invalidity
Medical report from the 1st treatment, medical reports from the course of treatment incl. possible operating protocol, confirmation by a doctor that the consequences are settled no earlier than one year after the accident
Hospital discharge report
Medical reports from the course of treatment, including a medical report when the disease was first diagnosed, a medical examiner's report on the declaration of invalidity, a decision indicating the date of declaration of invalidity
Medical report from the 1st treatment, medical reports from the course of treatment, as well as the decision on the onset and termination of temporary incapacity for work
Medical reports related to the death, officially certified copy of the death certificate, officially certified signature of the authorized person, and in the case of the reporting person, the selected type is other than the insured person
If the incident was handled by the Police of the Czech Republic, a copy of the police report must be provided

Upload files using Drag & Drop.

Images (JPEG, TIFF and PNG), documents (Word DOC / DOCX and PDF), workbooks (Excel XLS and XLSX) and compressed ZIP files are allowed. The maximum attachment size is 20 MB. Allowed characters for attachment name: letters, numbers, underscore, hyphen.

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Want to share your claim information with another person?

Enter the email to which we should send information about the occurrence of an insurance event

E-mail

Method of payment

Account number for payment of insurance benefits

If necessary, you can provide us with other essential information about the insurance event here.

Filing a claim