YOUR PERSONAL DATA
Fields marked with an asterisk have to be filled in. Insurant:
Address:
Business or private drive?:
Surname*:
First name*:
Phone no.*:
email* :
Motor vehicle third party liability:
Full coverage insurance:
Partial coverage insurance:
Deductible full coverage:
Deductible partial coverage:
Schadenereignis Date of loss*:
Schadenuhrzeit::
Location of loss*:
Vehicle registration number*:
Type of vehicle:
Driver*:
Address*:
Date of birth*:
Alcohol*:
Manufacturer:
Vehicle type:
Date of first registration:
Licence class*
since*:
Licence number*:
Issuing authority*:
Name:
Address:
Vehicle registration number:
Further vehicles:
What has been damaged?
Expected amount of loss:
Personal injuries:
Name / address:
Type of damage:
Expected amount of loss:
What has been damaged / stolen?
Where can the vehicle be inspected?
In case of theft: Had the doors been locked?
In case of theft: Had the windows been locked?
In case of theft: Had the ignition key been withdrawn?
In case of theft: Had the steering lock been engaged?
Has the vehicle and/or stolen objects been found again?
Does the vehicle belong to the business assets?:
Are you entitled to the deduction of input tax?
Security note:
Lessor:
Vehicle roadworthy?
Claims description*:
Visibility/
road condition*: Witnesses:
Please add other documents here (pictures, police report...):
Recorded by the police?*
File no.:
Police station:
Fine notice?:
Against whom?
Further documents:
Further documents:
Further documents:
Further documents:
