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Claim form

Name and address of the insurant
Family name: Given name:
Street
ZIP Code: Adress:
Insurance policy: Birthday:

INSTRUCTION: Please avoid any discussion with the injured party about his or her claim. Before you have been advised by your insurer you must neither admit neinr settle a claim. Any correspondence (particularly written claims, loss documentation, claims, orders to pay, applications for help in litigation or similar) are to be sent to the insurer immediately. Lodge a complaint immediately against any order to pay and raise an objection to any actions taken to enforce payment. Please neinte that every insurance accident must be reported in writing within one week, without delay. If the injured party makes a claim, you are required to report this within a week to the insurer.

Contact details:

Daytime phone
Daytime fax
Home phone
Home fax

email
Occupation/Organisation
Date of incident:
 Time:
 Place:

Description of accident

Injured party:

Family name: Given name:
Street: ZIP Code/adress
Phone daytime: Telefax daytime:
eMail: Privat:
Occupation/
Organisation 		Vorsteuerberechtigt: yes    no
Is the injured party related to you?
yes    no		 employed by you?
yes    no		 Form of relationship/
employment
your customer?
ja   nein		 a member of your household?
ja   nein		 your tenant
ja    nein

Responsible for accident:

Family name: Given name:
Street: Zip Code/adress:
Phone: FAX:
Occupation:
Reason and purpose for presence
at place of accident

VDWS Safety Tool / Card:

Where closed? (Name and full address)

Your report

Were you or aneinther insured person responsible
for the accident?		 no   yes, ground
Was a third party responsible for the accident? no  yes, grounds
Was there contributory negligence by
the injured party?		 no yes, grounds

Witnesses


Name and Adress

Police notification

nein    yes, address/department
Incident/log:
Complaint/police caution
no    yes, as

Injured party's Property

What items were damaged?
Type and extent of damage
Is repair possible? yes   no period of repair:
Year of purchase cost of repair
purchase price
Were the damaged items with you on hire?
yes   no		 on loan?
yes   no		 in safekeeping?
yes    no
to work on?
yes    no		 for repair?
yes    no		 for despatch?
yes    no
Where can the damaged items be examined?

Insured party´s Injuries

Accident at work at school?
 Medical treatment as
yes    no yes    no in patient out patient
Verletzte Person
Alter Fam.stand

Type and extent of injuries

Claims by the injured party

Have claims already been asserted against you?
no    yes, verbally schriftlich How much?
EUR
Do you believe the injured party's demands to be reasonable?
yes    no, why?
To whom shall the compensation be paid?

account number, bank code)
I certify by signing below that all the questions in this claims form have been answered fully and correctly. This also applies even in a case where I myself have neint written the answers. I understand that kneinwingly incorrect or incomplete details may lead to the loss of insurance protection, even when this has nein effect on the evaluation of the case, and do neint thereby result in any injury for the insurer.

After sending the claim form, you can send attachments such as photos, repair bills, purchase invoices, etc. to the notification of claim.

 

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