First name and surname
*
E-mail
*
Phone number
*
What's your case about?
*
O čemu je vaš slučaj?
Prometna nesreća
Ozljeda na radu
Povreda pravila medicinske struke
Żrtva zločina
Sportska ozljeda
Ozljeda djeteta
Nesreća u inozemstvu
The severity of injuries
*
Ozbiljnost ozljede
Ozljeda
Ozljeda s trajnim posljedicama
Smrt
Interest in advance payment of part of the claim
Interest in advance payment of part of the claim
Yes
No
Datum ozljede
Date
.
Day
.
Month
Year
Brief description of the incident
*
Date of submission
.
Day
.
Month
Year
Date
Pošalji
Should be Empty: