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Get a quote Report a claim

About Us
Insurance
Team
About Lloyd’s
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FAQ
Contacts
EN
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Report a claim

Please choose what type of claim you would like to report

Please choose what type of claim you would like to report

Directors & Officers Liability Insurance

General Liability Insurance

Directors & Officers Liability Insurance

Cyber Risk Insurance

Professional Indemnity Insurance

Cargo Insurance

Freight Services Liability Insurance

Personal Accident Insurance

Travel insurance

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General Liability Insurance Claim Reporting Form

Policyholder

Company name *

Company code *

Insurance policy number

* Compulsory field

Contact details of the rapporteur

Full Name *

Phone number *

Email *

Repeat your email *

Contact details of the claimant (if other than the rapporteur)

Full Name

Company Name

Phone number

Email

Accident date, time and location

Date *

Time *

City where the accident occured

Country where the accident occured

Description of a claim or circumstances that may lead to a claim (its nature, contents, etc.)

Were the people injured? *YesNo

Was the property damaged? *YesNo

Short description *

Police department (if reffered to after the event)

Name

Address

Date of reference

Time of reference

Does the insured hold itself liable for the loss?YesNo

Bank details for insurance indemnity transfer

Beneficiary name

Beneficiary bank account number

Notes and attached documents

Notes

Attached documents

Formal claimPhotos of the accidentContract based on which the works were performed / services deliveredDocuments substantiating the amount of damages claimedExplanation from the employee about the circumstances of the incidentReport of the competent authority (e.g., police, fire brigade, etc.)Correspondence between the policyholder and the claimantDefective actsFindings of independent expertsOther documents related to the event

Formal claim

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Photos of the accident

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Contract based on which the works were performed / services delivered

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Documents substantiating the amount of damages claimed

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Explanation from the employee about the circumstances of the incident

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Report of the competent authority (e.g., police, fire brigade, etc.)

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Correspondence between the policyholder and the claimant

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Defective acts

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Findings of independent experts

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Other documents related to the event

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Directors & Officers Liability Insurance Claim Reporting Form

Policyholder

Company name *

Company code *

Insurance policy number

* Compulsory field

Contact details of the rapporteur

Full name *

Phone number *

Email *

Repeat your email *

* Compulsory field

Contact details of the claimant (if other than the rapporteur)

Full name

Company name

Email

Phone number

Date when the claim was submitted or circumstances that may lead to a claim were notified

Date *

Description of a claim or circumstances that may lead to a claim (its nature, contents, etc.)

Short description *0 / 1000

Does the insured hold itself liable for the loss?

YesNo

Please specify

Notes and attached documents

Notes

Attached documents

Formal claimExplanation about the circumstances of the incidentDocuments substantiating the amount of damages claimedOther documents related to the event

Formal claim

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Explanation about the circumstances of the incident

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Documents substantiating the amount of damages claimed

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Other documents related to the event

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Cyber Insurance Claim Reporting Form

Policyholder

Company name *

Company code *

Insurance policy number

*Compulsory field

Contact details of the rapporteur

Full name *

Phone number *

Email *

Repeat your email *

Date and time when the suspected cyber accident was first noticed

Date *

Time

Nature and description of the accident

Please select *

Third party data lost / stolenOwn data lost / stolenComputer system damaged / corruptedCyber-attack suspectedOther

Short description of the accident0 / 1000

*Compulsory field

Where any state or other authorities notified about the accident?

YesNo

Name of authority *

Date of the notification *

Notes and attached documents

Notes

Copy of the emergency planReport of the competent authority (e.g., data protection authority, etc.) Formal claimDescription of the actions takenDocuments substantiating the amount of damages claimedOther documents related to the event

Copy of the emergency plan

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Report of the competent authority (e.g., data protection authority, etc.)

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Formal claim

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Description of the actions taken

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Documents substantiating the amount of damages claimed

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Other documents related to the event

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Attached documents

Copy of the emergency plan
Report of the competent authority (e.g., data protection authority, etc.)
Formal claim
Description of the actions taken
Documents substantiating the amount of damages claimed
Other documents related to the event

Professional Indemnity Insurance Claim Reporting Form

Policyholder

Company name *

Company code *

Insurance policy number

* Compulsory field

Contact details of the rapporteur

Full name *

Phone number *

Email *

Repeat your email *

Contact details of the claimant (if other than the rapporteur)

Full name

Company name

Email

Phone number

Date when the claim was submitted or circumstances that may lead to a claim were notified

Date *

Release date of a product / service from which the claim was or potentially could be derived

Date

Description of a claim or circumstances that may lead to a claim (its nature, contents, etc.)

Short description *0 / 1000

Does the insured hold itself liable for the loss?

YesNo

Please specify

Notes and attached documents

Notes

Attached documents

Formal claimContract based on which the works were performed / services deliveredExplanation about the circumstances of the incidentDocuments substantiating the amount of damages claimedOther documents related to the event

Formal claim

Drag and Drop (or) Choose Files

Contract based on which the works were performed / services delivered

Drag and Drop (or) Choose Files

Explanation about the circumstances of the incident

Drag and Drop (or) Choose Files

Documents substantiating the amount of damages claimed

Drag and Drop (or) Choose Files

Other documents related to the event

Drag and Drop (or) Choose Files

Cargo Insurance Claim Reporting Form

Policyholder

Company name *

Company code *

Insurance policy number

* Compulsory field

Contact details of the rapporteur

Full name *

Phone number *

Email *

Repeat your email *

Job Title

Contact details of the driver

Full name

Phone number

Contact details of the claimant (if other than the rapporteur)

Full name

Phone number

Email

Address

Cargo information

Consignment

Weight

Quantity

Waybill number

Consignment value

Implied loss amount

Accident date, time and location

Date *

Time *

Date when loss was noticed

City where the accident occured

Country where the accident occured

Additional details

Description of the accident *

Cargo condition, damages

Cargo rescuing measures taken

Was the incident reported to the police ?

YesNo

Name

Address

Date of reference

Time of reference

If police were not referred to, please indicate the reasons why this was not done

Date of survey (if performed)

Date

Is there any third party that might be held liable for the accident?

YesNo

Please specify

Notes and attached documents

Notes

Attached documents

Police reportCMR Waybill, TIR CARNETInvoiceCustoms declarationCarriage orderDrivers’ explanation about accident circumstancesTruck and trailer registration and technical inspection certificateSurvey report (unless ordered by the insurer)Refrigeration unit certificate of suitability (FRC, ATP)Claim (containing loss amount)Payment for the cargo documentsLoading, unloading documentsPictures of the damage

Police report
CMR Waybill, TIR CARNET
Invoice
Customs declaration
Carriage order
Drivers’ explanation about accident circumstances
Truck and trailer registration and technical inspection certificate
Survey report (unless ordered by the insurer)
Refrigeration unit certificate of suitability (FRC, ATP)
Claim (containing loss amount)
Payment for the cargo documents
Loading, unloading documents
Pictures of the damage

Police report

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CMR Waybill, TIR CARNET

Drag and Drop (or) Choose Files

Invoice

Drag and Drop (or) Choose Files

Customs declaration

Drag and Drop (or) Choose Files

Carriage order

Drag and Drop (or) Choose Files

Drivers’ explanation about accident circumstances

Drag and Drop (or) Choose Files

Truck and trailer registration and technical inspection certificate

Drag and Drop (or) Choose Files

Survey report (unless ordered by the insurer)

Drag and Drop (or) Choose Files

Refrigeration unit certificate of suitability (FRC, ATP)

Drag and Drop (or) Choose Files

Claim (containing loss amount)

Drag and Drop (or) Choose Files

Payment for the cargo documents

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Loading, unloading documents

Drag and Drop (or) Choose Files

Pictures of the damage

Drag and Drop (or) Choose Files

Freight Services Liability Insurance Claim Reporting Form

Policyholder

Company name *

Company code *

Insurance policy number

* Compulsory field

Contact details of the rapporteur

Full name *

Phone number *

Email *

Repeat your email *

Address

Contact details of the driver

Full name

Phone number

Contact details of the claimant (if other than the rapporteur)

Full name

Address

Email

Phone number

Cargo information

Consignment

Weight

Quantity

Waybill number

Consignment value

Implied loss amount

Accident date, time and location

Date *

Time *

City where the accident occured

Country where the accident occured

Additional details

Description of the accident *

Cargo condition, damages

Cargo rescuing measures taken

Was the incident reported to police?

YesNo

Name

Address

Date of reference

Time of reference

If police were not referred to, please indicate the reasons why this was not done

Date of survey (if performed)

Date

Notes and attached documents

Notes

Police reportCMR Waybill, TIR CARNETInvoiceCustoms declarationCarriage orderDrivers‘ explanation about accident circumstancesTruck and trailer registration and technical inspection certificateSurvey report (unless ordered by the insurer)Refrigeration unit certificate of suitability (FRC, ATP)Claim (containing loss amount)Payment for the cargo documentsLoading, unloading documentsPictures of the damage

Attached documents

Police report
CMR Waybill, TIR CARNET
Invoice
Customs declaration
Carriage order
Drivers‘ explanation about accident circumstances
Truck and trailer registration and technical inspection certificate
Survey report (unless ordered by the insurer)
Refrigeration unit certificate of suitability (FRC, ATP)
Claim (containing loss amount)
Payment for the cargo documents
Loading, unloading documents
Pictures of the damage

Police report

Drag and Drop (or) Choose Files

CMR Waybill, TIR CARNET

Drag and Drop (or) Choose Files

Invoice

Drag and Drop (or) Choose Files

Customs declaration

Drag and Drop (or) Choose Files

Carriage order

Drag and Drop (or) Choose Files

Drivers‘ explanation about accident circumstances

Drag and Drop (or) Choose Files

Truck and trailer registration and technical inspection certificate

Drag and Drop (or) Choose Files

Survey report (unless ordered by the insurer)

Drag and Drop (or) Choose Files

Refrigeration unit certificate of suitability (FRC, ATP)

Drag and Drop (or) Choose Files

Claim (containing loss amount)

Drag and Drop (or) Choose Files

Payment for the cargo documents

Drag and Drop (or) Choose Files

Loading, unloading documents

Drag and Drop (or) Choose Files

Pictures of the damage

Drag and Drop (or) Choose Files

Personal Accidents Insurance Claim Reporting Form

I am the injured personI am representative of the injured person

In connection with the claim submitted hereafter, I give Baltic Underwriting Agency, AB (BUNDA) a consent to use my genetic and biometric data, information about my health, sanctions compliance, social security benefits and claims, as per BUNDA Privacy Policy. *

I confirm that, in connection with the claim submitted hereafter, the injured person (the Principal) gives Baltic Underwriting Agency, AB (BUNDA) a consent to use his / her genetic and biometric data, information about his / her health, sanctions compliance, social security benefits and claims, as per BUNDA Privacy Policy.*

I understand that I can withdraw my consent at any time, but this may impede the claim adjustment procedure or make it impossible to implement.*

I confirm that the Principal understands that he / she can withdraw his / her consent at any time, but this may impede the claim adjustment procedure or make it impossible to implement.*

I agree that, if requested, third parties will provide BUNDA information and (or) documents, necessary for an event to be recognized an insured event, and(or) to determine the indemnity amount.*

I confirm that the Principal gives his / her consent for the third parties, if requested, to provide BUNDA with the information and (or) documents, necessary for an event to be recognized an insured event, and(or) to determine the indemnity amount.*

* Compulsory field

Contact details of the rapporteur

Full name *

Phone number *

Email *

Repeat your email *

Policyholder

Private personLegal person

Full name *

Date of birth *

Date of birth *

Insurance policy number

Company name *

Company Code *

Insurance policy number

Contact details of the injured person

Full name *

Date of birth *

Date of birth *

Job Title *

Phone number *

Address *

Email *

Accident details

Date of the accident *

City where the accident occurred

Country where the accident occurred

Circumstances of the accident *

Medical diagnosis

Police department (if referred to after the event)

Name

Address

Date of reference

Time of reference

Healthcare institution (if referred to after the event)

Name

Address

Date of reference

Time of reference

Insurance beneficiary

The injured person

Private personLegal person

Full Name *

Date of birth *

Date of birth *

Company name *

Company Code *

Bank account (IBAN) *

Which way would you like to receive the further information / requests regarding this claim?

By EmailBy post

Email *

Address *

Notes and attached documents

Notes

Attached documents

Medical reportConclusion of medical instrumental examination (X-ray examination, MRI, computed tomography, etc.)Incapacity documentEvidence of authorisation/representationCopy of ID card/passport of the InsuredPhotos from the accidentOther

Medical report

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Conclusion of medical instrumental examination (X-ray examination, MRI, computed tomography, etc.)

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Incapacity document

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Evidence of authorisation/representation

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Copy of ID card/passport of the Insured

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Photos from the accident

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Other

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Insurance products

General Liability Insurance
Directors & Officers Liability Insurance
Professional Indemnity Insurance
Cyber Risk Insurance
Cargo Insurance
Freight Services Liability Insurance
Personal Accidents Insurance
Corporate Travel Insurance

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