Submit a claim 1 Current: Start 2 Details of the loss/damage 3 Your details 4 Preview 5 Complete Required Indicates required field When did the incident occur? Required Date Required Time Required Town Required - Select -BavelBredaPrinsenbeekTeteringenUlvenhout Street Required Attention: only enter the name of the street and pay attention to the correct spelling. Enter house numbers and zip codes Description of the location. Description of the location Required Provide a clear description of the location where the incident occurred. For example, a house number, or the name of a commercial property. If possible, attach a map marking the location. Attachment Required One file only.100 MB limit.Allowed types: jpg, jpeg, png, pdf. What happened? Required State what happened and how this was able to happen. Were there any witnesses? Required Yes Required No Required How many witness statements are there? Required - Select -123 Witness 1 Required Name Required Adress Required Postal code Required House number Required House letter Required House letter addition Required Street name Required City Required Telephone number Required Statement Required Add the statement of the witness.One file only.100 MB limit.Allowed types: jpg, jpeg, png, odt, pdf, doc, docx. Witness 2 Required Name Required Adress Required Postal code Required House number Required House letter Required House letter addition Required Street name Required City Required Telephone number Required Statement Required Add the statement of the witness.One file only.100 MB limit.Allowed types: jpg, jpeg, png, odt, pdf, doc, docx. Witness 3 Required Name Required Adress Required Postal code Required House number Required House letter Required House letter addition Required Street name Required City Required Telephone number Required Statement Required Add the statement of the witness.One file only.100 MB limit.Allowed types: jpg, jpeg, png, odt, pdf, doc, docx. Leave this field blank Required