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Name and address of the insurant
Family nameGiven name Street ZIP Code Town, country/state
Date of birth
Insurance policy no.
INSTRUCTIONS: 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 nor 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 note 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 no. Email
Date of incident Time Place
Description of incident
Injured party
Family name Given name Street ZIP Code/ town, country/state Daytime phone no. Email Occupation/Organisation
Is the injured party entitled to deduct input tax yes no
Is the injured party related to you? yes no
Is the injured party employed by you? yes no
Is the party responsible for incident the insurant? yes no, give name and full Adress:
Family name Given name Street ZIP Code// town, country/state Phone Occupation
Reason and purpose for presence at place of incident:
VDWS Safety Tool / Card:
Where issued? (Name and full address)
Your report:
Were you or another insured person responsible for the incident? noyes, grounds
Was a third party responsible for the incident? no yes, grounds
Was there contributory negligence by the injured party? noyes, grounds
Witnesses
Police notification:
no yes, address/department
Incident no.
Injured party's property:
What items were damaged? (please specify item, manufacturer, model no.)
Type and extent of damage
Is repair possible? yes no
Length of repair Cost of repair Year of purchase 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:
Only complete this section if insurant is injured!
Medical treatment as in patient out patient
Injured person Age Material status
Type and extent of injuries
Claims by the injured party
Have claims already been asserted against you? no yes, verbally yes, writing
How much? EUR
Do you believe the injured party's demands to be reasonable? yes no, why?
Have you already paid for damages to the claimant?
no yes, in what amount and currency
Amount Currency
To whom should 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 not written the answers myself. I understand that knowingly supplied incorrect or incomplete details may lead to the loss of insurance protection, even when this has no effect on the evaluation of the case, and do not thereby result in any injury for the insurer.
Please do not forget to attach all the necessary documents and invoices for your claim!
We are able to handle and settle your claim once having received all the necessary documents. They must reach us within 3 weeks otherwise we will close the file without settlement.
In case of “comprehensive insurance” (damage of rented equipment) we need the following documents and invoices:
In case of general liability insurance (third party) we need the following documents and invoices:
If you press the button “send” you can still enclose the necessary documents.
