LEUE & NILL GmbH + Co. KG

Insuranceholder

First name

Last name

Street and Number

Country

ZIP code

City

Phone number

Faxnumber

Email address

Are you "Vorsteuerabzugsberechtigt"?

Insurancenumber

Damagedata

Date of damage

Time of damage

Damageplace and Street

police station

Diarynumber

Type of driving

Please enter destination and reason:

Has the driver been under the influence of alcohol or drugs?

Did the police took a blood sample ?

Own vehicle

Licence-plate-number

Manufakturer / Model

First registration

Mileage

Driver

First name

Last name

Street and Number

Country

ZIP code

City

Phone number

Faxnumber

Email address

Driving license class

Driving license date

Damaged vehicle parts

Amount of damage

Where can the damaged vehicle be inspected?

Amount of damage

Please start the marker with the button and select all damaged parts with your mouse

Type of vehicle

Other vehicle

Licence-plate-number

Manufakturer / Model

Construction Year

Mileage

Driver

First name

Last name

Street and Number

Country

ZIP code

City

Phone number

Faxnumber

Email address

Driving license class

Driving license date

Damaged vehicle parts

Amount of damage

Where can the damaged vehicle be inspected?

Amount of damage

Please start the marker with the button and select all damaged parts with your mouse

Type of vehicle

Personal injuries

Who owns the vehicle?

Own vehicle

Other vehicle

More details of the damage

Witnesses

Circumstances of the damage

Description

Attach files

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