Automobiles W. Dugrandpraz S.A.
Rte de la Florettaz 1
1275 Chéserex

Notification of claim

Vehicle owner

Salutation

Company name

Name *

First name *

Street

Zip * / Location *

Mobile phone *

Email *

The mobile number and email address will be used for further communication with you.

Vehicle

Brand *

Type *

License plate *

Kilometer total

Year of registration

Damage

Insurance *

Damage date *

Damage location *

Cause for damage

Circumstances of the accident *

* = mandatory field