Complaint form

Claimant information

Claimant type* Claimant type* The claimant type is private, if the claim of damage concerns a private person. The claimant type is commercial, if the claim of damage e.g. concerns a company

Is claimant a private person or a commercial entity?

Private

Commercial

Is the claimant the policyholder or a third party?*

You/the claimant is a third party if you/the claimant is not the person who has taken out the policy. If you/the claimant has taken out the policy yourself select no

The claimant is a third party

The claimant is the policyholder

Name of claimant*

Name of claimant*

Name of claimant*

Name of claimant*

Date of birth* The date of you/your client's birth

Date of birth* The date of you/your client's birth

Social security number* You/your client's personal identity number/national insurance number

Social security number*

VAT number* If the creditor does not have a VAT number, please choose "Private" and not "Commercial" under claimant type.

VAT* If the creditor does not have a VAT number, please choose "Private" and not "Commercial" under claimant type.

Address*

Address of company or department. If you report as an individual, it is your physical address.

Address of company or department. If you report as an individual, it is your physical address.

Country*

Denmark France Germany Ireland Italy Poland Romania United Kingdom Ukraine

Country*

Denmark France Germany Ireland Italy Poland Romania United Kingdom Ukraine

Country*

Denmark France Germany Ireland Italy Poland Romania United Kingdom Ukraine

Country*

Denmark France Germany Ireland Italy Poland Romania United Kingdom Ukraine

E-mail*

E-mail* The e-mail address that the company wishes to make inquiries to. If the company also has a contact, inquiries will be made to both the company's email address and the contact's email address.

E-mail*

E-mail* Your / Creditor's email address. We use the email address to send you messages about your review. You choose below if you want to receive messages, etc. by physical mail or by e-mail. We recommend that you use email addresses as it saves the cost of the bankruptcy estate.

ClaimForm.Filer.CreditorMail.Label

Confirm e-mail*

Confirm email*

Confirm e-mail*

Confirm e-mail*

ClaimForm.Filer.CreditorMailConfirm.Label

Phone number

Phone number

Phone number

Phone number

Phone number

Please state your telephone number including country code - e.g. +4412345678