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	Application form for a General Intervention
Fields in bold must be filled in

Applicant’s data

Name of Company Type of Company select insurance company broker firm other Name of the individual Address Pohen Number Zip Code Fax Town E-mail Prov. VAT number Possible notes for invoice

Type of intervention

Urgent   Ordinary       Type of damage select fire electric power event flood all risks ic products other     Object of the survey Value involved (if available)

Site of intervention

Name of the Company or site address Town Province Contact Mr/Ms Phone number

Damage documentation

Enclosed to this form     Only annexes     Follows by fax  fax n° +39-02-95341937     Not currently available

Notes and/or special instructions   How may we contact you? Phone   e-mail

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