Inquiry regarding the party at fault’s insurer

Affected by damage that occurred in one of the countries of the Green Card System caused by motor vehicles subject to registration, where the country of residence of the victim and the country of registration of the perpetrator vehicle were EEA countries or Switzerland.

Caution!

The form contains blocks that restrict the ability to select certain data. Its correct filling is only possible by adhering to the correct order of completion. If it can not be properly filled, it does not apply to the damage in question. If the injury took place in the country of residence of the victim (eg. Poland), the form does not apply. Please send a written request to This email address is being protected from spambots. You need JavaScript enabled to view it. for the purpose of establishing such data.

Fields marked with red color are mandatory.

Details of loss:
Details of person responsible:

(if known)

(if known)

Details of injured party:
Details of the applicant:


Declarations:
I declare that I am the person injured in the above-mentioned occurrence (or an attorney of the injured person). The ticking-off of this declaration is a precondition of the dispatch of the form.
Confirmation of getting acquainted about the information on personal data processing by Polish Motor Insurers’ Bureau. The ticking-off of this declaration of agreement is a precondition of the dispatch of the form. More information about the processing of your data you will find here.