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Personal injury claim form

Client data

1. Last name and first name: 2. Date of birth: 3. Address: 4. Postal code and city: 5. Are you registered in the Netherlands?: 6. Phone number: 7. Email address: 8. BSN number (identification number in the Netherlands): 9. Marital status: 10. Children (under 18 years old):

Accident details

11. Type of accident:

11a. As:

12. Date of accident: 13. Location: 14. Circumstances of the accident: 15. Type of injuries: 16. Witnesses: 17. Has the accident been reported?: 18. Ambulance transport:

18a. From... to:

19. Hospitalizacja:

19a. Where:

Course of treatment and therapies applied

20. Family doctor: 21. Physiotherapist: 22. Specialists: 23. Description of treatment:

Current complaints and limitations

24. Description of current complaints:

Employment details

25. Employer: 26. Self-employed: 27. Employment through an agency:

Losses related to the damage

28. Loss of work capacity:

Additional information

29. Health insurance: 30. Passenger insurance (if applicable): 31. Legal protection insurance:

Information about the opposing party

32. Company name or name of the offender: 33. Offender’s address: 34. City:

I consent to the processing of my personal data by the website administrator: Obronca.eu B.V, Zuidwenk 80 M, 3751 CG Bunschoten Spakenburg, The Netherlands, for the purpose of being contacted by the company. Detailed information about the processing of personal data can be found in the Privacy Policy.

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