YOUR PERSONAL DATA
Fields marked with an asterisk have to be filled in. Insurant:
Policy number:
Address:
Are you entitled to deduct input tax?
Surname*:
First name*:
Phone no.*:
email* :
Date of loss*:
Hour of loss*:
Location of loss*:
Party who caused the damage (insurant, spouse, son / daughter, staff member, other person, surname, first name, street, house no., postal code, city, phone no. if other than that of insurant, in case of children, state birth date and legal representative):
Address (street / house no. / postal code / city / phone / mobile phone):
Injured party (Surname, first name, company, in case of minors also the legal representative):
Address (street / house no. / postal code / city / phone / mobile phone):
Is the injured party entitled to deduct input tax?
Was there a family relationship/kinship between you/an additional insured and the injured party?
If so, which?
Was there an employment / salary / tenancy or other
contractual relationsship between you / an additional insured and the injured party?
If so, which?
Did you or an additional insured (e.g. staff member) perform any activity at or with the damaged object?
If so, which?
Description of loss (what was the cause and the circumstances of the loss, what has been damaged, are there any witnesses (name, address), is there a contributory negligence of the injured party?
Estimated amount of loss:
Have any liability claims already been asserted against you?
If so, which (add relevant papers)?:
Are the items damaged insured (e.g. glass, fire, electronics, vehicle comprehensive insurance)?
If so, state insurance, policy number and type of insurance.
Has the accident been recorded by the police?*
If so: police station / public prosecutor’s office, file no. (if available, hand in the certificate on the police report later):
Enclose documents:
Further documents:
Further documents:
Further documents:
