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SuedwestRing Insurance

Damage report third party liability

 

Insured person

Given name

Family name

Street

Country

ZIP Code

Town

Phone number

Email

Date of Birth

Job

Co-insured person (Information only required in SafetyTool Plus and insofar as this person has caused the damage)

Given name

Family name

Street

Country

ZIP Code

Town

Phone number

Email

Date of Birth

Job

relationship to the insured person

Information about your insurance

Does liability insurance with another insurance company exist (e.g. personal liability, boat iability, skipper’s liability insurance etc.)?

Please inform us about the insurance company, the policy number and the type of insurance

Information on the claimant

Company name

Given name

Family name

Street

Country

ZIP Code

Town

Phone number

Email

Are you related to the claimant?


Do you live in a common household with the claimant?


Do you have an employment contract with the claimant?


Is the claimant a crew member?


Who shall receive the claims payment?


Bank

IBAN

BIC

Unless your bank is located in the European Union, please also provide address and SWIFT code of the bank.

Bank details for the transfer of insurance payments

SWIFT

Description of the damage:

Loss date

Time

Place of damage

Reason and purpose of the stay at the place of damage

Description of the damage:

Is it your fault?


Reason

Is there fault on the part of a third party?


Did the injured party contribute to the damage?


Reason

Witness

Given name

Family name

Street

Country

ZIP Code

Town

Phone number

Email

Police notification:


address/department:

Journal number/ File number

In case of accidents while sailing or driving a motorboat, please also answer to the following questions:

Was the boat you lead




In case of property damage:

Damaged item (manufacturer, type, size)

year of acquisition:

Purchase price:

Serial number:

Was there any noticeable previous damage to the damaged material?


What damage, if any?

Is repair possible?


Time for repair:

repair costs:

Where can the damaged items be inspected?

Your opinion:

In case of bodily injury:

Medical treatment:


Nature and extent of the injury:

Claims of the injured party

Have claims already been asserted against you?


How much? EUR

Do you consider the injured party's claims to be reasonable?


Why?

Have you already settled the damage to the injured party?


If applicable, in which amount and currency:

Additional documents / attachments

By sending this form I confirm the correctness of my data.

Required field

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SüdwestRing Versicherungsmakler GmbH
Abt-Hyller-Straße 4 · 88250 Weingarten
Fon +49 751 56036-0 · Fax +49 751 56036-25
info@suedwestring.de