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Fri, 06/03/2011 - 15:30 — admin

Accident Declaration

Insured name: *

Address and Phone: *

Policy N°: *

Vehicle make: *

Plate N°: *

Driver at the moment of the accident

Driver name and age: *

Address and phone: *

License N° - Delivered on: *

Is he at your service?: *

Yes

Was he at your service at the moment of the accident?: *

Yes

Third party damage

Third party name: *

Third party vehicle make and N° : *

Specify the damage:

Damage to your vehicle

Specify damage to your vehicle:

Accident circumstances

Date and time: *

Location: *

Names and Addresses of any accident witnesses:

Name and N° of the policeman in charge:

Did you call an expert? If so, specify his name:

Accident details:

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Our addresses

Head Office

Jisr Al-Wati, Al-Ittihad Al-Watani Building
P.O.Box: 11-1270, Beirut, Lebanon
Telephone: +961 1-426480/1/2/3/4/5
Fax: +961 1-426486 - 422053
E-mail: webmaster@alittihadalwatani.com.lb

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