a3 GENERALI
CERERE DE DESPAGUBIRE Dosar nr. 2014 OSOADFD
Auto (marca,mode) Vy GOLF
Ne tnmatricutare Bey ces
subsermant = Saay Nicoza Reprozantan
‘cu domi in Avevecsa, Sada GHC ORGHE LARAR
we Sw Dd cas te ey et
ow OG HOH OBAONE wm _cxccomess
‘va rog $a aprobati plata despagubirt in suma de. 66 00 Ba
Solict plata despagubi
pe baza evalu Asiquratorau
[Ly recat do pty cr dep dane
Pentru solutonarea dosaruul anexez uimatoareleacte sociale:
Modalitatea de plata:
In conta bancar numaru!
BHR AEA au EEEQHE8E0
Banca POMER CAA ROUDEA ‘Sucurvete burie 4
Wieamentcatre ANB CONSTAHTIn Feoeuy
‘Raspund do exactittea,realtatea si corecttudinea actolor depuse.
ff.
iS
Am lata cunostint de precizare inscrise in procesul verbal de constatare a dauneor, cunoscand ca voi suporta
Consecintele ce decirg din neindepnirea obligato.
Decl prin prezenta ca, o dala cu primirea despagubii, nu mal am nico pretentie fata de Generali Romania Asigurare
Reasigurare SA. asiguraterl de raspundere civla si persoana vinovata. In cazul anulari actolorinchetale de organele de pole, unitate de pomp sau de catre alte autortati competente sa
coteateze acedontole de autovehicule, sulssomnatul (pagubit/ asigurat) ma obEp, prin somnaea prozontuli proces verbal
‘care ropreznia tity executoru, sa restiti bani in termen de cin ze dela data anlar actor.
(rice tontativa de obtinoro do foloase matorale nocuvenite din asigurare, se padopsoste confgrm Codull Penal.
bata AAA 2018 SEMNATURA 7
olor 4021 312 3835,
Fax +4021 912 37 20, Call Conor 04087201 02 02, woe. geneao, Ema nfo@gerealc, Ault de Conisla de Supraveghae 2
‘Asiguraror, Cad Unie PA002, EN ISO 90012008 Sse de Managorert al Cay, Crtel RG: 0174842007, CAF. RO 288862,
‘Capa cosa 170:100.9087 La eveatia ANSPOGP eum. 11758, | ROUMANIE ROMANIA’
CARTE Sea DE IDENTITATE IDENTITY
DIDENTITE ria RX nr 597885 iD
onp 190081441 0027
Nume/Nom/Last name” FeFSu
SANDU iM ENN}
Prenume/Prenom/First name Nt y
IN: ITIN-FLORIN 1k
Cetatenie/Nationalite/Nationality 1 Sex/Sexe/Sex
Romana / ROU
Loc nastere/Lieu de cere of birth
Mun. ;Bucuresti Sec.1
Domiciliu/Adresse/Address
Mun.Bucuresti Sec.1 Waly |
ek 5 Str.Gheorghe el nr.21 jet. Mansarda
Emisa de/Delivee parlssued Valabilitate/Valigite/Validity
@& SIP.CE.P. Sector 1 20.10.14-14.08.2021
|
IDROUSANDU<
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