ONLINE CARRIER'S LIABILITY NOTIFICATION

Dear Sir/Madam,

After successful submission of the online form, you will receive on the email address specified by you an automatically generated message to which you need not reply.

In order to submit to us an online notice of insured event, please provide true, correct and complete data in the electronic form, ensuring that all mandatory fields are filled in.

Online registration of a notice of insured event does not constitute release from any other obligations you have under the General Conditions of the Carrier’s liability insurance or from the instructions of the insurer.

Applicant:

Insured goods according to the commercial invoice:

City/Country

Day.Month.Year

we were informed by

Company which reported the damage

that during a carriage with truck with reg. No

damages of the cargo occurred as follows:

(description of damages; time and location of occurrence)

The subject-matter insured is currently located in

(name and address of the company where the cargo is located)

a letter of protest was sent by

(name of company which sent the protest)

(name of company addressed in the protest)

Name of the appointed average agent:

Date of inspection

Estimated damages

Date: 10.05.2024

Important Notice

The Insured is obliged to inform the insurer in case a claim or court action is brought against the insured, within the periods stated in the general conditions of the insurance contract.

I declare:

that I have access to internet and to the email address I have provided in my capacity of declarer of the insured event, on which email address I agree to receive all messages sent to me by BULSTRAD VIENNA INSURANCE GROUP in relation to the submitted notification and/or our contractual relations.

that I have received and I am familiar with the "Privacy Notice" provided by the Insurer in its capacity of data controller according to the requirements of Regulation (EU) 2016/679 (General Data Protection Regulation). I am informed that the "Privacy Notice" is also available on the Insurer's website – www.bulstrad.bg

that I am providing personal data of the Insured with the Insured’s consent, for the exercise of the Insured’s rights and for the discharge of the Insurer’s obligations under the concluded insurance contract.

that I am familiar with the "Rules on the activity of handling insurance claims" of the Insurer.