Damage Report Form

Incident type

Vehicle damage Road collision

Vehicle damage

Vehicle make:* Vehicle model:* Vehicle registration number:*

User details

User full name:* User ID card number:* User PESEL:* User postal code:* User city:* User street:* User building number:* User apartment number: User email address:* User contact number:*

Was the vehicle moving at the time of the incident?

Yes No

Driver details

Driver full name:* Nationality:* Driving licence number:* Issue date:* Expiry date:* Licence with no expiry Licence category:*

Incident details

Incident date:* Incident time:* Incident location postal code:* Incident location city:* Incident location street:* Incident location street number:*

Was the police present at the scene?

Yes

Police station name: Police station address: Case number:

Incident description:* Photos from the scene:

* I confirm that I have read the Privacy Policy and I consent to the processing of my personal data by Quanta Cars sp. z o.o. for the purpose of handling this report.

Road collision

Select your role in the incident:

I am the at-fault driver I am the injured party

Collision details

At-fault party details

At-fault vehicle make:* At-fault vehicle model:* At-fault vehicle registration number:*

At-fault insurer:* At-fault policy number:*

At-fault full name:* At-fault ID card number:* At-fault PESEL:* At-fault postal code:* At-fault city:* At-fault street:* At-fault building number:* At-fault apartment number: At-fault email:* At-fault phone number:*

Driver details (at-fault)

Driver full name:* Nationality:* Driving licence number:* Issue date:* Expiry date:* Licence with no expiry Licence category:*

Injured party details

Injured party vehicle make:* Injured party vehicle model:* Injured party vehicle registration number:* Injured party full name:* Injured party ID card number:* Injured party PESEL:* Injured party postal code:* Injured party city:* Injured party street:* Injured party building number:* Injured party apartment number: Injured party email:* Injured party phone number:*

Driver details (injured party)

Driver full name:* Nationality:* Driving licence number:* Issue date:* Expiry date:* Licence with no expiry Licence category:*

Incident details

Incident date:* Incident time:* Incident location postal code:* Incident location city:* Incident location street:* Incident location street number:*

Was the police present at the scene?

Yes

Police station name: Police station address: Case number:

Incident description:* Photos from the scene:

* I confirm that I have read the Privacy Policy and I consent to the processing of my personal data by Quanta Cars sp. z o.o. for the purpose of handling this report.