Afzender _______________________________________________________________________________________________
Aan _______________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Telefoonnummer __________________________________________________________________________________
______________________________________________________________________________________________________________
20
Aansprakelijkstelling
Betreft ongeval d.d.
te
Geachte heer/mevrouw
Op bovengenoemde datum vond een ongeval plaats waarbij uw voertuig betrokken was. Ik acht u aansprakelijk voor dit ongeval.
Indien u tegen wettelijke aansprakelijkheid bent verzekerd, verzoek ik u mij naam en adres van de maatschappij alsmede het polisnummer
waaronder u verzekerd bent op te geven. Tevens verzoek ik u deze aansprakelijkstelling door te zenden aan uw maatschappij.
Op bovengenoemde datum vond een ongeval plaats waarbij betrokken was uw verzekerde ____________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
verzekerd bij uw maatschappij onder polisnummer _________________________________________________________________________________________________________________________________________________________
Ik acht uw verzekerde aansprakelijk voor dit ongeval.
Gegevens betreffende het voertuig van uw verzekerde; merk ____________________________________________________________________ kenteken __________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Toedracht ongeval:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Getuigen:
naam
adres
postcode
woonplaats
telefoonnummer
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Gegevens betreffende mijn voertuig:
Merk en type ______________________________________________________________________________________________________________ bouwjaar _____________________________ kenteken _____________________________________
Plaatjenummer ___________________________________________________________________________________________________________ framenummer ____________________________________________________________________________
Mijn voertuig is tegen wettelijke aansprakelijkheid verzekerd bij verzekeringsmaatschappij __________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
onder polisnummer ____________________________________________________________________
De schade aan mijn voertuig wordt geschat op ________________________________________________________ en zal worden hersteld door ______________________________________________________
___________________________________________________________________________________________________________________________________
telefoonnummer reparateur _______________________________________________________
Voor expertise gelieve de expert zo spoedig mogelijk contact op te nemen met de reparateur of met mij.
Mijn beroep is _____________________________________________________________________________________________________________ loondienst
zelfstandig
De BTW, die in verband met dit schadegeval in rekening wordt gebracht, kan ik
wel
niet verrekenen
Reden ______________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Mijn bankrekening-/gironummer is ___________________________________________________________________________________________________________________________________________________________________________________
Uw berichten zie ik met belangstelling tegemoet.
Hoogachtend,
______________________________________________________________________________________________________
D-3217-07-01