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1
Event
2
Circumstances
3
Reimbursment
4
Confirmation
Date and time of the event
Please mark the point on the map!
Address of the accident
Claim reporter
Name
Last name
Identity number
E-mail
Phone
Insurance policy
Policy number
Policy holder
Individual
Legal person
Name
Last name
Identity number
Legal name
Reģistrācijas numurs
E-pasta adrese
Tālruņa numurs
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