Form to report accident not involving others - KBC Autolease

1) Your contact details

Number plate

Company

Surname of driver at the time of the accident

First name of driver at the time of the accident

E-mail address of driver at the time of the accident

Mobile phone number of driver at the time of the accident

2) Circumstances of the accident

Date of the accident

Location of the accident

Describe the circumstances of the accident

Did the police visit the scene of the accident?

Yes No

Police report number

Did the driver take an alcohol test?

Yes No

What was the result of the alcohol test?

Positive Negative

3) Roadside assistance

Did you call in the VAB roadside breakdown rescue service?

Yes No

Do you have a VAB replacement car?

Yes No

Was your vehicle towed?

Yes No

To where?

4) Describe all of the damage to vehicle.

5) Repairs

KBC Autolease 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/autolease/privacy, at your branch or from your intermediary and is regularly revised.