Report form for theft or accident involving a lease bike

1Contact details

Identification number / your bicycle number plate

Employer

Surname of contractual rider

First name of contractual rider

Address of contractual rider

E-mail address of contractual rider

Surname of rider at time of accident

First name of rider at time of accident

Address of rider at time of accident

Mobile phone number of rider at time of accident

2Circumstances:

Date of incident

Location of incident

Describe in detail what happened

Please send us the official report number.

Upload a copy of the full police interview report

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Please provide us with the name and contact details (including, if possible, the address) of the witness or witnesses.

Is there any other relevant information that might be important to your file?

Describe in detail what happened

If so, please contact your third-party liability insurer and/or legal assistance insurer.

Other party’s surname

Other party’s first name

Other party’s address

Vehicle make and model (if applicable)

Number plate (if applicable)

Insurance company:

Policy number:

Please provide us with a copy of the accident statement

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What is the official report number?

Please provide us with a copy of the full police interview report

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Please provide us with the name and full address of the witness or witnesses

Describe the damage to your bicycle

To where?

What you have to do next:

Take your bicycle to the dealer where you bought it and have the damage assessed. Please send us:

A detailed estimate of the damage

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Photos of the damage to the bicycle

Photo 1

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Photo 2

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Photo 3

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Photo 4

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A general photo of the damaged bicycle

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If you're unable to upload the estimate and photos right now, send the requested items to fietsschade@kbcautolease.be later.

IMPORTANT: the dealer may not repair your bicycle without our prior consent!

KBC Insurance aims to process your personal data in a manner that is lawful, appropriate and transparent. Further details about how we process and share your personal data are set out in our privacy statement. It explains your rights and how you can exercise them. Our privacy statement is available at www.kbc.be/privacy, at your branch or from your intermediary and is regularly revised.

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