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Information about the policy holder

Form of adress *

First name *

Surname *

Date of birth *

Company name *

Phone number

Street address *

Postcode *

City *

Notice of claim

Please answer the following questions so that we can help you quickly and settle the damages to your satisfaction. Many thanks.

*

When did the damage occur? *

Damage location (street, house no., postcode, city)?

Please describe how the damage occurred *

Please select the liability risk: *

Who caused the damage? *

Name and address?

Who caused the damage? *

Name and adress of the employee.

Name and adress of the subcontractor.

Did the subcontractor already claim the damage to his/her liability insurance?

Name and adress of the insurer and the reference number.

Why did the sucontractor not claim the damage to his insurance?

Name and adress of the other persons?

How many persons, including policyholder, family members and trainees etc. were employed in the company on the day of the damage?

Please specify the order, the damage occured at.

Since when does your company do such activities?

Who was the customer for the work you did there?

Were you subcontractor?

Who caused the damage? *

Name and adress of the other person?

In what capacity did you attend the hunt?

Please describe the other capacity.

In case of material damage: Kind of damage? *

In case of personal injury: Kind of damage? *

Reason of benefit in case of personal injuries?Leistungsgrund bei Personenschaeden? *

Reason of benefit in case of material damages? *

Reason of benefit in case of financial damages? *

Reason of benefit in case of rental damages? *

In case of damages caused by animals

Kind, breed, name and estimate height of the animal?

Since when is the animal in your posession?

The animal's age?

Does the animal serve your profession or employment?

Who observed the animal (name and adress)?

How many animals of the same kind, as the one that caused the damage, have you had on the day of the damage?

In case of damages caused by children

First name and surname of the child?

Date of birth of the child?

When the damage occured, did the child have a full education? *

Specification of education? *

Start of the education? *

End of the education? *

Married? *

Since when? *

In case of damages caused by animals

kind, breed, name and estimate height of the animal?

Since when is the animal in your posession?

The animal's age?

Does the animal serve your profession or employment?

Who observed the animal (name and adress)?

How many animals of the same kind, as the one that caused the damage, have you had on the day of the damage?

While driving a vehicle or a working machine?

Number plate of the damage causing vehicle/ working machine?

Type of vehicle, kind of vehicle, producer?

Maximum speed due to construction?

Date of purchase of the vehicle/machine

Did the driver have the correct drinving license to drive the specific vehicle when the damage occured?

In case of water damage (e.g. caused by washing machine or similar)

When has the device been purchased?

When has the device been connected?

Has the device been in service by a specialized company regularly?

When did the last service happen?

Could you have noticed the leaking water immediately, if you would have had a higher amount of attention?

In which intervals have you checked the vehicles progress?

In case of damages on motor vehicles

Number plate, type of vehicle and producer of the damaged vehicle?

Where can the vehicle be examined?

Breach of duty to take care (e.g. room/duty to strew sand)

When and by whom (exakt name and adress) has the street been cleared/sanded the last time?

Did it snow since the last cleaning and the accident continously?

In case of damages in House and land ownership (within commercial liability)

What kind of landowner risk is this about?

Do you only use it for living?

When has the roof/facade been checked or repaired the last time by a specialized company?

Name and adress of the specialized company?

In case of damages in Builder-owner liability

Please enter the expected construction costs.

Were the planning, the lead of the construction, the execution of the construction assigned to third parties?

Questions to the damaged items:

*

How do you estimate the extent of the cost of repair?

EUR

Did you possess the damaged item due to rent, borrow, leasing or similar? *

Which legal relation? *

Did the injured party agree to you using the item? *

Did the damage occur because you were using the damaged item for your employment or commercially? (e.g. with editing, reparation, transport, inspesction etc.)

Did the damage occur on an item, you created or delivered yourself?

When the damage occured, has the item already been paid for by the client/injured party?

Details to injuries:

Which injuries did the injured party suffer from? (Kind of injuries)

Expected extent of claim for damages?

EUR

Details about injured parties and liability

Form of adress *

First name *

Surname *

Company name *

Street address *

Postcode *

City *

Phone number

Email

Is there a familar connection between you? *

Which familiar connection?

Does the injured party live in the same household with you? *

Is there a working-, salary-, rental or other contractual relationship betwenn you?

Which?

Did the damage causer act in favour?

When were the claims against you being made?

Do you think you are responsible for the damage?

Why do you not think, you are being responsible?

Do you think the injured party has complicity?

Where do you see the complicity?

Do you think anybody else has complicity too?

Who and why?

Are you making claims for compensations yourself?

Against who and why?

Who should the compensation be transferred to? *

Why should the compensation not be transferred to the injured party/claimant?

Please specify name, adress and in how the person is related to the damage (e.g. repair company).

Please enter a your bank details with your IBAN.

In case there are multiple injured parties, please insert these here (name, adress).

Are there witnesses to the damage?

Details to witnesses

Form of adress

First name

Surname

Street address

Postcode

City

Phone number

Email

I am reporting the damage

In my capacity as: *

First name *

Surname *

*

Agency number?

Instruction about contractual obligations

I hereby confirm the accuracy of the input.

Notification according to section 28, paragraph 4 VVG on the consequences of breaches of contractual obligations

Obligation of information and disclosure

After the occurence of the insured event, we can demand full disclosure on necessary information to identitfy the insured event or to state our contractual liability, according to the contractual ageerement with you (obligation of information). Furthermore, we need you to provide us with all the necessary information to clarify the state of affairs and to examine our duty to provide benefits appropiately (obligation of disclosure). Additional, we can ask you to provide reiceipts for us, as far you can be reasonably expected to do so.

Freedom of claims

In case you are, contrary to the contractual agreement, either holding back information, intentional making any false statements or intentional holding back receipts we demanded, you will lose your right for insurance benefit. In case of grossly negligent violence of the contractual obligation, you will not lose the whole right for insurance benefit, but we can reduce our reimbursement in proportion of your culpability. If you can proof, that there has been no gross negligence hurt of the obliagtions, there will be no reduction of payment. Despite of any violation of the obligation according to information, disclosure and the procurement of receipts, we stay obligated to pay, if you can proof, that the violation of obligation has not been causal to the examination of the insured event or the extent of the damage and its payment. In case of fraudulent violation of the obligations to information, disclosure and the procurement of receipts, we will free from our liability to pay in any case.

Notice:

If another party than you enjoys the right of the contractual insurance service, this party is obligated to fulfil the obligation of information, disclosure and procurement of receipts.

Notice of claim

Information about the policy holder

Notice of claim

In case of damages caused by animals

In case of damages caused by children

In case of damages caused by animals

While driving a vehicle or a working machine?

In case of water damage (e.g. caused by washing machine or similar)

In case of damages on motor vehicles

Breach of duty to take care (e.g. room/duty to strew sand)

In case of damages in House and land ownership (within commercial liability)

In case of damages in Builder-owner liability

Questions to the damaged items:

Details to injuries:

Details about injured parties and liability

Details to witnesses

I am reporting the damage

Instruction about contractual obligations

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