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Breakdown Report
Company information
Name reporter (required)
Company (required)
Email (required)
Phone (required)
Already a customer? (required)
Yes
No
Invoice to (Departement, Leasing company, etc.)
Please complete the additional company information below!
Company address (required)
Postal Code (required)
City (required)
Country (required)
VAT number (required)
Breakdown Information
Your reference / Case number (will show on invoice.)
Your cost code (will show on invoice.)
Type of Breakdown? (required)
Please complete the breakdown information fields below!
Licence plate number Truck (required)
VIN / Chassis number (required)
Brand (required)
Problem (required)
Licence plate number Trailer (required)
ILU Code
Brand (required)
Fleetnumber
VIN/Chassis number (required)
Problem (required)
Licence plate number (required)
Axle (required)
Tire size (required)
Side? (required)
Right
Left
Rim Dimension
Replacement tire? (required)
Steer
Drive
Trailer/Boogie
M+S Required? (required)
Yes
No
Licence plate number (required)
Length (required)
Brand (required)
Total weight (including load) (required)
Trailer connected? (required)
Yes
No
Destination (required)
Location Information
Location? (required)
Exact Address
Highway or main road
Kombiterminal or Harbour
Please complete the location information fields below!
Address (required)
City (required)
Road number (required)
Direction? (required)
North
East
South
West
Nearest city (required)
In dangerous position? (required)
Yes
No
Latitude (required)
Longtitude (required)
City (required)
Terminal/Harbour Name (required)
Booked for train/ferry (required)
Yes
No
Time Departure(required)
Driver present? (required)
Yes
No
Phone number driver (required)
I hereby guarantee payment up to:
Amount in EURO(required)
I hereby guarantee payment up to:
Amount in EURO (required)
I hereby guarantee payment up to:
Amount in EURO(required)
I hereby guarantee payment up to:
Amount in EURO(required)
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Other important information
Subject
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