ADDENDUM

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Seria. YD Nr. 120862994

$VLJXUăWRU Allianz Tiriac Asigurari SA CUI 6120740

Asigurat/Contractant Pieknyi Daniel Ioan CNP/CUI 1931103204505
Utilizator - CNP/CUI -

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Acoperire 6XPăDVLJXUDWă/LPLWDGHVSăJXELULL 3ULPăGHDVLJXUDUH
3URWHFWLHMXULGLFă 15.000 RON 5 RON
$VLVWHQĠăUXWLHUă%DVLF FRQIRUPFRQGLĠLL 15 RON
Asigurare persoane Basic 'HFHV,QYDOLGLWDWHWHPSRUDUă521 4 RON
,QYDOLGLWDWHSHUPDQHQWWRWDOă521
5ăVSXQGHUHFLYLOăDXWR5&$ conform contract de asigurare 1324 RON
7RWDOSULPăGHDVLJXUDUH 1348 RON
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asigurare cod CSAS 11.2014Ghid de beneficii auto cod GBA v.6 octombrie 2022

Pentru a &HQWUXOGH'DXQH&DOO&HQWHUGHOXQLSkQăYLQHULvQWUHRUHOHVLODQXPHUHOHGHWHOHIRQ

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producerea 8:00 si 20:00 sau
unei daune, - Mondial Assistance (24 ore din 24) la numerele de telefon 00402 131 22239/00431 525 03 65 51
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ASIGURAT/CONTRACTANT, ASIGURATOR,
ALLIANZ ±ğ,5,$&$6,*85$5,6$
Pieknyi Daniel Ioan Safety Broker De Asigurare S.A. /
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6HFWRU%XFXUHúWL5RPkQLD 6RFLHWDWHDXWRUL]DWăGH$XWRULWDWHDGH6XSUDYHJKHUH)LQDQFLDUă
Telefon 021 2082 222 &RGXODORFDWvQ5HJLVWUXODVLJXUăWRULORUúLUHDVLJXUăWRULORU5$
Fax 021 2082 211 Codul LEI 529900XKNXM9MBH8GS45
www.allianztiriac.ro Operator de date cu caracter personal nr. 779
EN ISO 9001:2015

29
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9.
PENTRU AUTOVEHICULE ISSUED UNDER THE AUTHORITY OF: Name and Address of the Policyholder (or User of the vehicle)
1. INTERNATIONAL MOTOR INSURANCE CARD %,528/8,$6,*85Ă725,/25'( Pieknyi Daniel Ioan, Adresa: Uricani, judet
1. CARTE INTERNATIONALE D'ASSURANCE AUTOVEHICULE DIN ROMÂNIA
AUTOMOBILE (B.A.A.R.) Hunedoara, str. Brazilor, nr. 1, bl. D9, et. 1,
ap. 1
3. VALABILITATE - V A L I D 4. &RGXOĠăULL&RGXODVLJXUăWRUXOXL1XPăUXOSROLĠHL
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Country This Card has been issued by : Signature of Insurer
Ziua - Day Luna - Month Anul - Year Ziua - Day Luna - Month Anul - Year
Code/Insurer`s Code/Number
6&$//,$1=ğ,5,$&$6,*85Ă5,6$
28 04 2023 27 04 2024
RO/07/R7/YD Str. Buzesti, nr. 82-94, etajele 3,4,12,
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120862994
1UGHFLUFXODĠLHVDXvQOLSVăQULGHQWLILFDUHVDXQUGH 6. Categoria 7. Marca vehiculului
motor vehiculului / Make of Vehicle
Registration No.(or if none) Chassis or Engine No. Category of
Vehicle*
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HD64RAN A Peugeot Înregistrat la ORC sub nr. J40/15882/1994, CUI: 6120740
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Codul LEI 529900XKNXM9MBH8GS45
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EN ISO 9001:2015

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A B BG CY CZ D DK E EST F FIN
GR H HR I IRL IS L LT LV M N
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UA UK
CODUL CATEGORIILOR DE VEHICULE:
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&LSUXúL6HUELDHVWHOLPLWDWăODDULDJHRJUDILFăDDFHVWRUVWDWHFDUHHVWHVXEFRQWUROXOJXYHUQHORUUHVSHFWLYH A. AUTOTURISM/CAR E. AUTOBUS SAU AUTOCAR/BUS
3HQWUXPDLPXOWHLQIRUPDĠLLFRQVXOWDĠLKWWSJFWHUULWRULDOYDOLGLW\FRE[RUJ
B. MOTOCICLU/MOTORCYCLE F. REMORCA/TRAILER
C. AUTOCAMION SAU TRACTOR/LORRY OR TRACTOR G. ALTELE/OTHERS
D. BICICLETA CU MOTOR/CYCLE FITTED WITH AUXILIARY ENGINE

&2175$&7'($6,*85$5('(5Ă6381'(5(&,9,/Ă$8725&$ Seria RO/07/R7/YD Nr.

R.C J40/15882/1994 C.U.I. 6120740
120862994
Denumire asigurator:$//,$1=ğ,5,$&$6,*85Ă5,6$
Broker / Agent Safety Broker De Asigurare S.A. / / Tel/Fax:
Agentia Muntenia - Brokeri Cod RBK-293
Nume/Denumire Asigurat/ )HO7LS0DUFă0RGHO A, Autoturism, Peugeot,
Pieknyi Daniel Ioan
Proprietar: Vehicul: 407 Sw
C.U.I. / C.N.P. Proprietar: 1931103204505 Nr. înmatriculare/înregistrare: HD64RAN
Nume/Denumire Asigurat/ Nr.identificare - Serie CIV / VF36ERHRH21674944 /
Utilizator: nr.de inventar: P077001
C.U.I. / C.N.P. Utilizator: &DSDFLWDWHFLOLQGULFă3XWHUH 1.997 cmc / 100 kw
$GUHVă$VLJXUDW8WLOL]DWRU Uricani, judet Hunedoara, str. Brazilor, nr. 1UORFXULPDVăWRWDOă
5 / 2.195 kg
Tel. / E-mail 1, bl. D9, et. 1, ap. 1 PD[LPăDXWRUL]DWă

Conducatori auto declarati:

Pieknyi Daniel Ioan 1931103204505;
(Nume, prenume, CNP)
Valabilitate Contract de la 28.04.2023 SkQăOD 27.04.2024 Contract emis în data 27.04.2023
Prima de asigurare 1324 RON Clasa Bonus Malus B1 7DULIGHFRQWDUHGLUHFWă - 7RWDOSODWă 1348 RON
Nr. Rate* 1 Valoare rate Rata 1: 1348 RON Date scadente Rata 1: 27.04.2023
3ULPDUDWăvQFDVDWăFX în data 27.04.2023
/LPLWDGHGHVSăJXELUHSHQWUXYăWăPDULFRUSRUDOHúLGHFHV 6.070.000 EURO
/LPLWDGHGHVSăJXELUHSHQWUXGDXQHPDWHULDOH 1.220.000 EURO
Acoperiri/servicii suplimentare: Accidente persoane, Asistenta rutiera
2EVHUYDЙLL Canal comunicare oferta reinnoire RCA:

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atrage încetarea contractului de asigurare! Vezi detalii pe verso.
#Error 0
 NOTA PENTRU ASIGURAT
In ceea ce priveste (a) avarierea vehiculului asigurat, indiferent de modalitatea de producere a acesteia; (b) vatamarile corporale care nu sunt acoperite conform legislatiei privind asigurarea de raspundere civila obligatorie din tara in care a avut
loc accidentul; (c) reinnoirea unei Carti Verzi a carei valabilitate a expirat, Biroul din tara vizitata nu trebuie sa fie contactat, ci se va contacta direct asiguratorul , daca nu exista alte instructiuni din partea asiguratoruloui.
NOTE TO THE INSURED
In regard to (a) damage to the insured vehicle, however caused; (b) personal injuries not covered by the Compulsory Third Party Insurance Law in force in the country of accident; c) renewal of a card the validity of wich has expired; the Bureau
of the country visited should not be approached but notification should be given (unless otherwise instructed by the Insurer) direct to the Insurer.
DENUMIRILE SI ADRESELE BIROURILOR

A AUSTRIA VERBAND DER VERSICHERUNGSUNTERNEHMEN OSTERREICHS IS ICELAND ALPJÓDLEGAR BIFREIDATRYGGINGAR Á ISLANDI, Borgartuni 35, 105
Schwarzenbergplats 7, Postfach 248, A-1030 WIEN :[43] (1) 711 560 REYKJAVIK, :[354] 568 1612,
AL ALBANIA BSHS BYROJA SHQIPTARE E SIGURIMIT, Rruga µ¶Gjergj Fishta´Pall Edil-Al-lt, Kati L LUXENBOURG BUREAU LUXEMBOURGEOIS DES ASSUREURS,12, rue Erasme, L-1468,
II-te, TIRANA : [355] (42) 54033 LUXEMBOURG :[352] 45 73 04
AND ANDORRA OFICINA ANDORRANA D¶ENTITATS D¶ASSEGURANCA D¶AUTOMOBIL, c/o Maria LT LITHUANIA MOTOR INSURERS¶BUREAU OF THE REPUBLIC OF LITHUANIA , Algirdo 38, LT-
Pla., 33, 3r, 3a, AD500 ANDORRA LA VELLA : [376] 86 00 17 03606 VILNIUS, :[370] 5 216 28 60
AZ AZERBAIJAN COMPULSORY INSURANCE BUREAU SAT PLAZA, 11-th floor, 133 Bashir Safaroglu LV LATVIA LATVIJAS TRANSPORTIDZEKLU APDROŠINATAJU BIROJS (Motor insurers¶bureau
Street., BAKU, AZ1009 : [+994 12] 595 00 20 of Latvia) , 9 Lomonosova Street, Riga LV-1019 :[371] 67 114 30
B BELGIUM BUREAU BELGE DES ASSUREURS AUTOMOBILES, Rue de la Charité 33 Bte 2, BE- M MALTA MALTA GREEN CARD BUREAU, 43A/4 St. Paul¶s Buildings, West Street, VALLETTA
1210 BRUXELLES : [32] (2) 287 18 VLT 1532, :[356] 21 238 253, [356] 21 232 640,
BG BULGARIA NATIONAL BUREAU OF BULGARIAN MOTOR INSURERS, 2, Graf Ignatiev Str, 2nd MA MAROCCO BUREAU CENTRAL MAROCAIN DES STES D¶ASSURANCES, 154 Blvd d¶Anfa, 01-
floor, SOFIA 1000 : [359] (2) 981 11 03 CASABLANCA 20050, :[212] (522) 39 18 57 :[212] (522) 39 18 59
BIH BOSNIA AND HERTEGOVINA BIRO ZELENE KARTE U BOSNI I HERCEGOVINI, Dervisa Numica MD MOLDOVA NATIONAL BUREAU OF MOTOR INSURERS OF MOLDOVA (NBMIM), 16
7, 71000 SARAJEVO : [387] (33) 610 744 .RJăOQLFHDQXVWU&+,6,1$8:[373] 22 221 970
BY BELARUS BELARUSIAN TRANSPORT INSURANCE BUREAU, 29-70 Pritytskogo Str., MINSK MK NORTH MACEDONIA NATIONAL INSURANCE BUREAU, ³Mitropolit Trodosij Galanov´str.
: [375] (17) 209 85 25 no.28/IV SKOPJE, : [389] (2) 3136 172
CH SWITZERLAND NATIONALES VERSICHERUNGSBURO SCHWEIZ (NVB)/ SWISS NATIONAL MNE ASSOCIATION NATIONAL BUREAU OF MONTENEGRO INSURES, PC Europoint,
BUREAU OF INSURANCE (NBI),P.O. Box, CH-8085 Zurich :[41] (44) 628 65 19 ± MONTENEGRO Svetlane Kane Radevic 3/II Podgorica 81000 PODGORICA, :[382] (20) 243 440
Secretariat,[41] (44) 628 89 30 ±Claims N NORWAY TRAFIKKFORSIKRINGSFORENINGEN, Hansteens gate 2, Postboks 2551 Solli, 0202
CY CYPRUS MOTOR INSURERS¶FUND, 23, Zenon Sozos Str, P.O. Box 22025 1516 NICOSIA : OSLO, :[47] (23) 28 42 0
[357] (22) 763 913 ,[357] (22) 764 907 NL NETHERLANDS NEDERLANDS BUREAU DER MOTORRIJTUIGVERZEKERAARS, Handelskade 49
CZ CZECH REP CESKA KANCELAR POJISTITELU, Na Pankraci 1724/129, 140 00 PRAHA 4, :[420] NL-2288 BA RIJSWIJK ZH, :[31] (70) 340 82 80
221 413 660 P PORTUGAL GABINETE PORTUGUÊS DE CARTA VERDE-GPCV, Rua Rodrigo da Fonseca no.41, P-
D GERMANY DEUTSCHES BURO GRUNE KARTE E.V. Wilhelmstrasse 43/43 G, D-10117 Berlin , : 1250 190 LISBOA, :[351] (21) 384 8101/ 02
[49] (30) 2020 57 57 PL POLAND POLISH MOTOR INSUERS¶BUREAU, Ul. Swietokrzyska 14, PL 00-050 WARSAW, :
DK DENMARK DANSK FORENING FOR INTERNATIONAL MOTORKORETOJSFORSIKRING, Philip [48] (22) 826 46 33
Heymans Alle 1, DK-2900 HELLERUP, :[45] (41) 91 91 91 RO ROMANIA BIROUL ASIGURATORILOR DE AUTOVEHICULE DIN ROMANIA (B.A.A.R.) 40-
E SPAIN OFICINA ESPAÑOLA DE ASEGURADORES DE AUTOMOVILES, Sagasta 18, 28004 ELV9DVLOH/DVFăU6WUHHW%8&+$5(67FRGH:[40] (21) 319 13 02/ 03
MADRID, :[34] (91) 446 03 00 RUS RUSSIA RUSSIAN ASSOCIATION OF MOTOR INSURERS, 27 bld. 3, Lusinovskaya str., 115093
EST ESTONIA EESTI LIIKLUSKINDLUSTUSE FOND, Mustamäe tee 46, 10621 TALLINN, :[372] 667 MOSKOW, Secretariat: [7] (495) 771 69 47 Claims: [7] (495) 641 27 8
1800 S SWEDEN TRAFIKFORSAKRINGSFORENINGEN, Karlavagen 108, STOCKHOLM/ Box 24035,
F FRANCE BUREAU CENTRAL FRANÇAIS, 1, rue Jules Lefebvre, 75431 Paris Cedex 09 , :[33] SE-104 50 STOCKHOLM, :[46] (8) 522 782 00
(1) 53 21 50 80 SRB SERBIA UDRUZENJE OSIGURAVACA SRBIJE, Milentija Popovica 5b/11, 11000 BELGRADE,
FIN FINLAND LIIKENNEVAKUUTUSKESKUS, Itämerenkatu 11-13 HELSINKI FIN-00180, :[358] (0) :[381] (11) 29 27 950
404 504 520 SK SLOVAK REP SLOVENSKÁ KANCELÁRIA POIST¶OVATEL¶OV, Bajikalska 19B, 826 58
GR GREECE MOTOR INSURERS¶BUREAU ±GREECE, 9 Xenophontos Street, ATHENS 105 57, : BRATISLAVA 29, :[421] 2 4444 5452
[30] (210) 32 23 324 [30] (210) 32 36 562 SLO SLOVENIA SLOVENSKO ZAVAROVALNO ZDRUZENJE, GIZ, 1001 LJUBLJANA, Zelezna cesta
H HUNGARY MAGYAR BISTOSITOK SZOVETSEGE (MABISZ) Hungarian Motor Insurance Bureau, 14, :[386] (1) 4735 322
Andrassy ut 93, H-1062 BUDAPEST/, POB 1297, H-1381 BUDAPEST 62, :[36] (1) 802 TN TUNISIA BUREAU UNIFIE AUTOMOBILE TUNISIEN, 85-87 Rue Palestine, 1002 TUNIS
8400 Belvedere , :[ 216] 71 841 514, [216] 71 841 784
HR CROATIA HRVATSKI URED ZA OSIGURANJE, Croatian Insurance Bureau, 10000 ZAGREB, TR TURKEY TURKIYE MOTORLU TASIT BUROSU (TURKISH MOTOR INSURANCE BUREAU) ,
Martieva 71, :[385] (1) 46 96 600 Buyukdere Cad. Oya Sk. Devran Apt. 2/1, 34394 Gayrettepe, ISTANBUL, :[90] (212) 217
I ITALY UFFICIO CENTRALE ITALIANO, (U.C.I.) SOC. CONS. A.R.L., 20145 MILANO, Corso 5968 69/ 70 /71
Sempione 39, :[39] (02) 34 96 81 UA UKRAINE MOTOR (TRANSPORT) INSURANCE BUREAU OF UKRAINE, , P.O.B. 272, KYIV-2,
IR ISLAMIC REP. GREEN CARD BUREAU OF IRAN, C/O BIMEH MARKAZI IRAN ,No. 2, corner of 02002, :[38] (044) 239 20 27
OF IRAN Maryam St., Nelson Mandela Ave. -196776411 ±POB 19395-5588 ±TEHRAN-IRAN, : UK UNITED KINGDOM OF GREAT-BRITAIN AND NORTHERN IRELAND MOTOR
[98] (21) 24 55 1000 INSURERS¶BUREAU ±UK, Linford Wood House 6-12, Capital Drive, Linford
IRL IRLANDA MOTOR INSURERS¶BUREAU OF IRELAND 5 Harbourmaster Place, IFSC, Dublin 1, Wood, MILTON KEYNES MK14 6XT, Telefon:[44] (1908) 830 0
IRELAND : [353] (1) 676 9944

Pentru informatii suplimentare va rugam sa accesati: www.cobx.org

Conditiile contractuale sunt cele prevazute prin dispozitiile Legii nr. 132/2017 privind asigurarea obligatorie de raspundere civila
auto pentru prejudicii produse tertilor prin accidente de vehicule si tramvaie si cele ale legislatiei secundare emise de catre A.S.F.
(Norma RCA 20/2017) in aplicarea acesteia ce se regasesc postate pe siteul Allianz Tiriac.
Acestea pot fi completate si cu alte prevederi/clauze suplimentare ce sunt stabilite de comun acord de catre asigurat si asigurator si
sunt prevazute intr-un act aditional la prezentul contract.
Contractul RCA, inclusiv orice act aditional sau anexa la acesta constituie titlu executoriu pentru ratele scadente si neachitate, in
conformitate cu prevederile Art. 5 alin. (3) din Legea nr. 132/2017 privind asigurarea obligatorie de raspundere civila auto pentru
prejudicii produse tertilor prin accidente de vehicule si tramvaie.
In cazul in care Contractantul/Asiguratul nu plateste prima de asigurare conform prevederilor agreate, la termenele stabilite
in polita de asigurare, Asiguratorul va rezilia (inceta) polita fara nicio notificare prealabila, iar aceasta nu va mai produce
niciun efect fata de tertii pagubiti sau autoritatile statului.
Contractul RCA da dreptul persoanei prejudiciate, in cazul producerii unui prejudiciu, sa se poata adresa pentru efectuarea reparatiei
oricarei unitati reparatoare auto, in conditiile legii, fara nicio restrictie sau constrangere din partea asiguratorului RCA sau a unitatii
reparatoare auto, care ar putea sa-i influenteze optiunea.
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