Claim form no.

Vehicle Operator identification data
Vehicle Operator number: Toll account number:
Toll payment regime: Licence plate number:
Vehicle Operator company
name/business name/name and
surname:
Contact person name and
surname:
Registered office/permanent
residence/place of business:
City:
Postcode: Country:
Company ID No.: VAT ID No.:
Dear customer, information regarding the electronic toll collection can be obtained on the web portal www.emyto.sk or through the customer service line on +421 2 3511 1111.

Tax ID No.: Date of birth:
Phone number: E­mail:

Claim description
Type of claim: Claim
Reason of claim:

Claim attachments:

Data for claim form
Point of sale number: Staff ID:
Point of sale address:
Date of receipt:

In case that the method of claim application and its settlement was carried out pursuant to the relevant provisions of the General Business Terms
and Conditions of the Toll Collection Administrator as well as of the General Business Terms and Conditions of the System Operator, the System
Operator notifies you of the fact that your 0 was received and the reply to this 0 shall be sent to you pursuant to the aforesaid General Business
Terms and Conditions.

Place, date: Place, date:
Signature of the authorised person Signature of the Vehicle Operator
of the Toll Collection or its authorised representative
Administrator: (possibly the company seal):

SkyToll, a. s., Lamačská cesta 3/B, 841 04 Bratislava, Slovak republic

E­mail: info@emyto.sk
ID No.: 44 500 734, Tax ID No.: 2022712153, VAT No.: SK2022712153
Company is registered at Companies Register of the District Court I. in Section: Sa, Insert No.: 4646/B 1/1