Date of Birth
relationship to the insured person
Does liability insurance with another insurance company exist (e.g. personal liability, boat iability, skipper’s liability insurance etc.)?
Yes, another insurance exists
Please inform us about the insurance company, the policy number and the type of insurance
No, I don’t have another insurance.
No, the rental station/ charter operator/ boat doesn’t have another insurance.
Company name / family name
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?
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
Place of damage
Reason and purpose of the stay at the place of damage
Description of the damage:
Is it your fault?
Is there fault on the part of a third party?
Did the injured party contribute to the damage?
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
with you on hire?
with a crewmember on hire?
with you on loan?
in your property?
Damaged item (manufacturer, type, size)
year of acquisition:
Was there any noticeable previous damage to the damaged material?
What damage, if any?
Is repair possible?
Time for repair:
Where can the damaged items be inspected?
Nature and extent of the injury:
Have claims already been asserted against you?
How much? EUR
Do you consider the injured party's claims to be reasonable?
Have you already settled the damage to the injured party?
If applicable, in which amount and currency:
By sending this form I confirm the correctness of my data.