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:
Devices concerned / electronics (Manufacturer, type, device number):
Are you the owner of the device?
Where did you lease the device, rent or take as security (name, address, phone number)?:
Which building work is concerned (street, house number, postal code, city)?:
Are temporary buildings or building materials concerned?
Has the partial performance or the overall performance been finished?
If so, since when?
Put to use?
If so, since when?
Accepted?
If so, since when?
What is affected?
When did the assembly start?
Has the system been acceptance-tested?
If so, since when?
Description of loss (What was the reason, what was the course of events, who caused the damage (surname, first name, address), what has been damaged, which parts have to be repaired and / or replaced):
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):
Have any changes or improvements been made in the course of the repair?
If so, please name the insurance company, policy number and type of insurance:
Where can the damaged parts/objects been inspected? (name, address, phone number)?
Is there any other insurance protection for the loss, e.g. fire / storm:
If so, please name the insurance company, policy number and type of insurance:
Has it been recorded by the police (theft and fire always has to be reported to the police)?*:
Police station / file number:
Enclose documents:
Further documents:
Further documents:
Further documents:
