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Annuncio di sinistro protezione giuridica della circolazione
Annuncio di sinistro protezione giuridica della circolazione Stipulante No di rif. _________________________________________________________________________________________________ Cognome Nome Via, No ________________________________________________________________________ o _______________________________________________________________________________________________ ______________________________________________________________________________________________________ ____________________________________________________________________________________________________ NPA, località Email Assicurazione malati, associazione, sindacato ______________________________________________________________________________________ N di Polizza _______________________________________________________________________________________________ Data di nascita Tel. privato Tel. prof. ___________________________________________________________________________________________ ___________________________________________________________________________________________________ ________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Generalità ed indirizzo della persona assicurata, unicamente se non si tratta dello stipulante ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Modalità di pagamento Conto bancario Conto corrente postale Banca No. C.C.P.: Sede _______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Conto bancario (IBAN) __________________________________________________________________ Il conto è intestato a nome di: ____________________________________________________________ Coop Protezione Giuridica SA I www.cooprecht.ch Viale Stazione 31 I 6500 Bellinzona I T. +41 91 825 81 80 I F. +41 91 825 95 15 I [email protected] Che cosa è successo? Descrizione esatta e dettagliata, schizzo, ev. foto __________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Nei confronti di chi intende rivendicare il danno subito? Nome, Cognome Indirizzo _____________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________ NPA, località ________________________________________________________________________________________________ Nominativo dell’assicurazione responsabilità civile avversa? Compagnia e indirizzo dell‘assicurazione No di polizza _______________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________________________________ È stato steso un rapporto di polizia, in caso affermativo, presso quale posto? posto ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Nell’eventualità in cui fosse stato unicamente redatto un protocollo d‘incidente, è gentilmente pregato di volerlo allegare. Se ha già ricevuto eventuali communicazioni inerenti una procedura penale/amministrativa a suo carico, la invitiamo gentilmente a volerci fare immediatamente pervenire l’eventuale documentazione in suo possesso onde pterci permettere di preservare I previsti termini legali di opposizione. Coop Protezione Giuridica SA I www.cooprecht.ch Viale Stazione 31 I 6500 Bellinzona I T. +41 91 825 81 80 I F. +41 91 825 95 15 I [email protected] Ci sono testimoni noti? Nome, Cognome Indirizzo ____________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________ NPA, località ________________________________________________________________________________________________ È stato ferito? In caso affermativo: genere delle ferite. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Nominativo della sua assicurazione contro gli infortuni? Compagnia e indirizzo dell‘assicurazione No di polizza _______________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Ha subito un danno materiale, se si, quale? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Generalità detentore veicolo coinvolto? Nominativo assicurazione responsabilità civile e casco? Nome, Cognome Indirizzo ____________________________________________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________ No di targa veicolo coinvolto NPA, località ________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________ Nome, indirizo e No di polizza di Assicurazione responsabilità civile Assicurazione casco totale _____________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________ Assicurazione casco parziale __________________________________________________________________________________________________________________________________________________________________________________________ Coop Protezione Giuridica SA I www.cooprecht.ch Viale Stazione 31 I 6500 Bellinzona I T. +41 91 825 81 80 I F. +41 91 825 95 15 I [email protected] Generalità conducente veicolo coinvolto? Nome, Cognome Indirizzo ____________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________ NPA, località ________________________________________________________________________________________________ Al momento dove si trova il veicolo? Nome, Cognome Indirizzo ____________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________ NPA, località _________________________________________________________________________________________________ Altre assicurazioni di protezione giuridica È in possesso di altre assicurazioni di protezione giuridica Se si, quale? sì no ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ Scelta d’un avvocato Lascia a noi la scelta dell‘avvocato? In caso contrario chi propone? sì no ____________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Luogo e data firma ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Attaccamento protocollo d‘incidente documentazione inerente una procedura penale/amministrativa schizzo foto Coop Protezione Giuridica SA I www.cooprecht.ch Viale Stazione 31 I 6500 Bellinzona I T. +41 91 825 81 80 I F. +41 91 825 95 15 I [email protected]
