VRSTA ŠTETE __________________

BROJ:________________________ DATUM I MJESTO :_____________________________________

VLASNIK :_________________________________________________________________________
REG.BROJ :_________________________ ŠASIJA :___________________________________
VRSTA :_________________________ MOTOR :___________________________________
MARKA :_________________________ GOD.PROIZ. :___________________________________
TIP :_________________________ KW/𝒄𝒎𝟑 :___________________________________
PRVA REG. :_________________________ VRATA :___________________________________
KILOMERAŽA :_______________________ BOJA :___________________________________
STANJE VOZILA :______________________________________________________________________

a.) DIJELOVI ZA ZAMJENU b.) DIJELOVI ZA POPRAVKU

ŠTETA (datum, mjesto, događaj):___________________________________________________________________