FCGA - Belgian motor garentee fund

NON IDENTIFICATION	NON INSURANCE	FORTUITOUS EVENT	THEFT

DECLARANT
Surname *
First name *
Address *
Ref.
e-Mail *
VICTIM / CLAIMANT
Surname
First name
Address
Ref.
e-Mail
Male		Female
Date of birth

Date of accident		Location
Country of occurrence
An intervention can be considered only if the facts are duly establish by evidences.
QUALITY OF THE CLAIMANT
	Driver of a motorized vehicle
	Passenger of a motorized vehicle
	Pedestrian
	Cyclist
	Building
	Other