Reporting an insurance claim

To report an insurance claim, please fill in the fields below (required fields are marked with an asterisk) and submit the report to Drivalia Lease Czech Republic s.r.o. using the Submit button at the bottom of the form.
In case of any doubts or queries on processing an insurance claim on the vehicle, you will be contacted by our staff in order to fill and specify any additional details, so that the insurance event can be properly claimed.

1. Contact details of the person filling out this claim

Name

Surname

Phone number

E-mail

2. Reporting a vehicle insurance claim to Drivalia

Type of damage

Own fault (damage to Drivalia vehicle only)

Own fault (another vehicle / property / person damaged by Drivalia vehicle)

Fault of another person (another vehicle - known offender)

Fault of an unknown offender (another vehicle unknown to us, unknown offender)

Damage by other means (e.g. collision with wildlife, rodent, natural event - windstorm, hail)

3. Details about how the damage happened, its cause and location of the event

Date of damage

Time

Street, street number, roadway, highway number

City, municipality

District

Country

Brief description of the event

4. Drivalia Lease Czech Republic s.r.o. Vehicle

Vehicle make and model

Registration number

Extent of the damage

5. Driver

Same contact as the above

Yes

Name

Surname

Phone number

E-mail

Residence - street and street number

City, municipality

Postal code

Driver's license number

Type of driver's license

6. Contact person at your company for possible supplementary information to add to this event

Same contact as the person filling out this form

Yes

Name

Surname

Phone number

E-mail

7. Information about the Police

Investigated by the Police

Yes

Department name

Reference number

Address

City, municipality

Phone number

The reason for not reporting the event to the Police

Has an agreement on the fault been reached and written with the other party?

Yes

8. Another accident participant (damaged, harmful vehicle)

This section is filled only during the actual fault or blame by another person (you fill in the entry point 2)

Vehicle make and model

Registration number

Extent of the damage

Driver

Name

Surname

Phone number

E-mail

The other party of the accident or its representative

Name

Surname

Phone number

E-mail

Owner

Same as the driver filled in the section „Other party to the accident“

Yes

Name and surname / name of the company

Phone number

E-mail

Address: Street and street number

City, municipality

Postal code

Country

Information on the other party's insurance company

This section is filled out only in case of own fault (Drivalia vehicle damaged another vehicle/person/property) or in case of fault by another person (please fill in the entry field 2)

Name of the insurance company

Green card number / insurance contract number

9. Additional information you may have about the insurance claim (photos, Police protocol, report on the traffic accident, etc.)

Note: In case of damage caused by another participant, it is absolutely necessary to know as much information as possible (addresses, telephone number, etc.)

Attachment No. 1

Attachment No. 2

Attachment No. 3

Attachment No. 4

Attachment No. 5

Attachment No. 6

10. DRIVER'S SERVICE for insurance claims

If you are interested in having your vehicle repaired through DRIVER'S SERVICE for insurance claims , please provide the additional information and we will arrange the repair for you shortly. (If you're sending this request outside of business hours or on weekends, you will be offered this option on the next business day.)

Driver's service is an optional service consisting of a comprehensive solution for vehicle repair after a damage event. It includes finding a suitable car service, suitable date and providing a replacement vehicle free of charge according to the supplier's availability and capacity.

I am interested in arranging a repair date for my vehicle. Glass repair/replacement can be done directly at your designated location under certain conditions.

Address where the service representative can pick up the vehicle

Your desired repair date

Your notes

Drivalia is committed to protecting and securing the personal information it collects and processes. More information on the conditions of personal data processing can be found in Statement on Privacy.

Items marked with * are mandatory.