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Registration form

Please make a choice

All fields marked with an asterisk (*) are mandatory.

1. Data of the adult filing the accident claim: 

a) Identity

Please fill in your first name(s)
Please fill in your name (using only letters and these special characters: à,â,ä,é,è,ê,ë,ï,î,ô,ö,ù,ü,û,ç,ÿ,ß,æ,œ,-,‘)
Date of birth:*
Please select your date of birth from the list and note that you must be at least 18 years old
Please fill in your place of birth (using only letters and special characters)
Please select your nationality from the list

b) Legal address and contact data

Please fill in your address
Please fill in your house number (using only letters and/or numbers )
Please fill in your box number (using only letters, numbers or - )
Please fill in your zip code (using only letters, numbers and -)
Please fill in your city/municipality
Please select your country from the list
Please fill in the email address and make sure to use a correct syntax
The e-mail address doesn't match
Please fill in the phone number (using only numbers and/or specials characters: (, ), /, . , + or - )

c) Situation and position :

I'm filing this claim:*
I'm filing this claim:
Please make a choice
I'm filing this claim:*
I'm filing this claim:
Please make a choice

All fields marked with an asterisk (*) are mandatory.

This part of the form concerns only victims.
If there is more than one victim, please fill in this part of the form multiple times. 

2. Information regarding the VICTIM:

a) Identity of the victim

Please fill in the first name(s) of the victim (using only letters and these special characters: à,â,ä,é,è,ê,ë,ï,î,ô,ö,ù,ü,û,ç,ÿ,ß,æ,œ,-,‘)
Please fill in the name of the victim (using only letters and these special characters: à,â,ä,é,è,ê,ë,ï,î,ô,ö,ù,ü,û,ç,ÿ,ß,æ,œ,-,‘)
Date of birth:*
Please fill in the date of birth of the victim from the list
Please fill in the place of birth of the victim (using only letters and these special characters: à,â,ä,é,è,ê,ë,ï,î,ô,ö,ù,ü,û,ç,ÿ,ß,æ,œ,-,‘)
Please fill in the nationality of the victim from the list

b) Legal address and contact data of the victim

Please fill in the address of the victim (using only letters and these special characters: à,â,ä,é,è,ê,ë,ï,î,ô,ö,ù,ü,û,ç,ÿ,ß,æ,œ,-,‘,.)
Please fill in the house number of the victim (using only letters and/or numbers )
Please fill in the box number of the victim (using only letters, numbers or -)
Please fill in the zip code of the victim (using only letters, numbers and -)
Please fill in the city of the victim
Please fill in the country of the victim from the list
Please fill in the email address of the victim and make sure to use a correct syntax
The e-mail address doesn't match
Please fill in the phone number of the victim (using only numbers and/or specials characters: (,), /, . , + or - )

c) Damages suffered

1. Bodily injury: *

Please select the applicable answer

2. Material damage: *

Please select the applicable answer

3. Consequential damage due to bodily injury and/or material damage: *

Please select the applicable answer

4. Costs and/or consequential damage caused by the proclaimed preventive measures: *

Please select the applicable answer

All fields marked with an asterisk (*) are mandatory.

2. Information regarding the COMPANY or the ASSOCIATION:

a. Legal identity of the (headquarters of the) company or association 

Please fill in the company name
Please select a country
Please provide a valid Belgian VAT number, in the format BE0000000000
Please fill in your address (using only letters and these special characters: à,â,ä,é,è,ê,ë,ï,î,ô,ö,ù,ü,û,ç,ÿ,ß,æ,œ,-,‘,.)
Please fill in your house number (using only letters and/or numbers )
Please fill in your box number (using only letters, numbers or - )
Please fill in your zip code (using only letters, numbers and -)
Please fill in your city (using only letters and these special characters: à,â,ä,é,è,ê,ë,ï,î,ô,ö,ù,ü,û,ç,ÿ,ß,æ,œ,-,‘)
Insurance company with which a fire insurance is taken
Please select your fire insurance company from the list. If it isn't listed, you can select "Other" at the end.
Please fill in the fire policy number

b) Where did the damage occur?

Branch/establishment where the incident occurred*
Branch/establishment where the incident occurred
Please fill in the company name
Please select a country
Please fill in your address (using only letters and these special characters: à,â,ä,é,è,ê,ë,ï,î,ô,ö,ù,ü,û,ç,ÿ,ß,æ,œ,-,‘,.)
Please fill in your house number (using only letters and/or numbers )
Please fill in your box number (using only letters, numbers or - )
Please fill in your zip code (using only letters, numbers and -)
Please fill in a city
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c) Information regarding the damage suffered:

Material damage : *

Please select the applicable answer

Consequential damage due to material damage: *

Please select the applicable answer

Costs of measures of reinstatement of impaired environment : *

Please select the applicable answer

Loss of income due to inability to use the environment for commercial purposes : *

Please select the applicable answer

Costs and/or consequential damage caused by the proclaimed preventive measures : *

Please select the applicable answer

Attention! It appears that a claim has already been made for this victim. If you still wish to continue, please tick the checkbox below. If you wish to quit, you can simply close the form.

I agree*
I agree
Please tick this box

All fields marked with an asterisk (*) are mandatory.

3. Brief description of the damage suffered

0/5000

Please fill in the comment field (using only letters, numbers and these special characters: à,â,ä,é,è,ê,ë,ï,î,ô,ö,ù,ü,û,ç,ÿ,ß,æ,œ,-,',‘,’,.,:,!,?,(,),%,/,\)
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I took notice of the Privacy Notice. Please check the box below.

Please confirm that you have read the privacy notice
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