Type of Incident
Vehicle Damage
Collision with Another Vehicle
I am the Culprit
I am the Victim
Vehicle Details
Brand:
Model:
License Plate Number:
Personal Details
Full Name:
ID Number:
PESEL Number:
Postal Code:
City:
Street:
House Number:
Apartment Number:
Email Address:
Contact Number:
Incident Details
Date:
Time:
Postal Code:
City:
Street:
Street Number:
Was the police on the scene?
Police Station Name:
Police Station Address:
Case/Note Number:
Incident Circumstances
Describe what happened:
Add damage photos:
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