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*:
The loss relates to the following sector*:
Cause of loss (burglary, robbery, bicycle theft, fire, lightning, explosion,
pipe burst, frost, storm, hail, elemental damage, other):
Description of loss (What was the reason and what was the course of events, who caused the loss, secure the evidences and make photos of the damaged objects)*:
Details as to the amount of loss (list of the damaged parts stating the year of purchase and price, please add purchase receipts and photos of the damage):
Are you the owner of the object?
Where did you lease, rent the objects or take as security
(name, address, phone):
Is there any other insurance protection for the damage, e.g. electronics insurance
If so, please name the insurance company, policy number and type of insurance
Has the event been recorded by the police?*
File no.:
Police station:
Enclose documents:
Further documents:
Further documents:
Further documents:
