INDEXO Purchase insurance claims form

Information about you

Name, Surname

Personal code

Phone number

E-mail

Information about the accident

What happened?

Accident date

Accident place (address)

Have you informed the police about the accident?

Yes No

Accident photos and purchase confirmation documents

Please upload a printout from the internet bank confirming the purchase made with your INDEXO card. As well as photographs or other documents of the damaged purchase (up to 4 MB).

Please provide your bank account number for claims payout

Bank account number

I certify that the information provided in this application is true and accurate. I understand that providing false or misleading information may result in If P&C Insurance AS Latvian branch withholding insurance compensation and I may be subject to criminal liability for fraud under Article 177 and Article 178 of the Latvian Criminal Law.

Yes, I certify

P&C Insurance AS Latvia branch will use the information you provide about yourself and the accident in accordance with Privacy notice to:

evaluate your claim and make a decision on the compensation;
exchange information with state registers as required by regulatory acts;
contact you.

* Nepieciešams aizpildīt lauku

Pieteikums tiek sūtīts...