Prijava Å¡kodnega primera iz zavarovanja avtomobilskega kaska
Prijava Å¡kodnega primera iz zavarovanja avtomobilskega kaska
Prijava Å¡kodnega primera iz zavarovanja avtomobilskega kaska
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ZAVAROVALNICA TRIGLAV, D.D.<br />
miklošièeva cesta 19, ljubljana<br />
ID št. za DDV SI80040306<br />
Številka škodnega spisa: .........................................................................................................<br />
<strong>iz</strong>polni zavarovalnica<br />
<strong>Prijava</strong> škodnega <strong>primera</strong> <strong>iz</strong><br />
<strong>zavarovanja</strong> <strong>avtomobilskega</strong> <strong>kaska</strong><br />
1. Zavarovanec (priimek in ime oz. firma) in njegov naslov: ..............................................................................................................................................................................................................................<br />
..............................................................................................................................................................................................................................................................................................................................................................................<br />
................................................................................................................................... , davèna številka: ................................................................ , tel. številka: .........................................................................................<br />
e-mail: .................................................................................................................. , TRR št.: ....................................................................................... , odprt pri banki: ............................................................................... .<br />
imam(o) sklenjeno zavarovanje <strong>avtomobilskega</strong> <strong>kaska</strong> za motorno vozilo:<br />
registrska oznaèba:<br />
datum prve registracije:<br />
vrsta vozila: znamka vozila: tip vozila:<br />
številka šasije: leto <strong>iz</strong>delave: prevoženi kilometri:<br />
pri Zavarovalnici Triglav, d.d., obmoèna/poslovna enota: .................................................................................................. , s polico številka: ........................................................................... .<br />
Zavarovanje velja za èas od .................................................................... do .............................................................. .<br />
2. Voznik (priimek in ime): ................................................................................................................................................................................................................ , davèna številka: .................................................... .<br />
Naslov: .......................................................................................................................................................................................................................................................................................................................................................... .<br />
Številka vozniškega dovoljenja: .......................................................................... , kategorija: .................... , datum opravljenega <strong>iz</strong>pita za kategorijo: .................................................... ,<br />
Podatke preveril(a): ........................................................................................................ , Podpis: .......................................................................................... .<br />
(<strong>iz</strong>polni odgovorni delavec zavarovalnice)<br />
3. Škodni primer se je zgodil dne: ................................................................................... v (med) ..................................................................................................................................... ob .............................. uri.<br />
Kako in zakaj je prišlo do škodnega <strong>primera</strong> (opišite potek prometne nesreèe, vrsto in stanje vozišèa ter vremenske razmere): ...........................................<br />
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Skica dogodka (oznaèite vozila, smeri gibanja vozil in položaj vozil ob trèenju):<br />
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PV-aka-sp/09-5
4. Kdo je po vašem mnenju odgovoren za škodni primer in zakaj ..............................................................................................................................................................................................................<br />
..............................................................................................................................................................................................................................................................................................................................................................................<br />
5. Ogled prometne nesreèe je opravila postaja policije (navedite postajo): .........................................................................................................................................................................................<br />
Pri ustreznem odgovoru prekrižajte prazen kvadrat.<br />
Ali je bil opravljen alkotest ¨ da ¨ ne<br />
Ali je voznik alkotest odklonil ¨ da ¨ ne<br />
Ali je bil voznik odpeljan na odvzem krvi, urina ¨ da ¨ ne<br />
Ali je voznik vozil pod vplivom alkohola, mamil ¨ da ¨ ne<br />
Ali je bilo vozilo že kdaj poškodovano ¨ da ¨ ne<br />
Namen vožnje: ¨ službeno ¨ privatno<br />
6. S kakšno hitrostjo ste vozili, ko se je zgodila prometna nesreèa .........................................................................................................................................................................................................<br />
7. Ime, priimek in naslov lastnika oz. voznika pri prometni nesreèi soudeleženega vozila ter registrska oznaèba vozila: .......................................................................<br />
..............................................................................................................................................................................................................................................................................................................................................................................<br />
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8. Imena, priimki in naslovi oseb, ki so bile v vašem vozilu: .................................................................................................................................................................................................................................<br />
..............................................................................................................................................................................................................................................................................................................................................................................<br />
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9. Imena, priimki in naslovi priè škodnega dogodka: ...................................................................................................................................................................................................................................................<br />
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............................................................................................................................................................................................................................................................................................................................................................................. .<br />
10. Ogled poškodovanih stvari je možen (kje, èe niso dostavljene na ogledno mesto) ............................................................................................................................................................... .<br />
11. Opis poškodb na vozilu:<br />
S pušèico oznaèite mesto poškodb na vozilu<br />
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12. Vse poškodovane in ob popravilu zamenjane dele je zavarovanec dolžan shraniti do <strong>iz</strong>plaèila zavarovalnine.<br />
13. Strinjam se, da ta dokumetn velja tudi kot prijava škodnega <strong>primera</strong> <strong>iz</strong> <strong>zavarovanja</strong> avtomobilske odgovornosti:<br />
¨ da ¨ ne<br />
(S potrditvijo tega teksta omogoèate enostavnejše in hitrejše uveljavljanje odškodnin tretjih oseb, za škode, ki ste jih s svojim vozilom povzroèili<br />
na predmetih in osebah v tej prometni nezgodi. V zvezi s tem vas prosimo, da natanèno <strong>iz</strong>polnite toèke 4., 5.,7., in 8.)<br />
Opomba: Podpisani jamèim, da so vsi navedeni podatki resnièni. Zavestno neresnièno navajanje podatkov lahko pomeni kaznivo dejanje goljufije po<br />
2. odstavku 211. èlena Kazenskega zakonika KZ-1.<br />
.................................................................................... , dne ..................................................................... . ............................................................................................................................................................<br />
Zavarovanec
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