Damage report third party liability

Given name

Family name

Street

Country

ZIP Code

Town

Telephone

Your 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

Telephone

Your email

Date of Birth

Job

Information about your insurance

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

Yes another insurance existsNo I don't have another insuranceNo the station/ charter operator/ boat doesn;t have another insurance

Information on the claimant

Given name

Family name

Street

Country

ZIP Code

Town

Telephone

Claimant email

Are you related to the claimant?

YesNo

Do you live in a common household with the claimant?

YesNo

Do you have an employment contract with the claimant?

YesNo

Is the claimant a crew member?

YesNo

Who shall receive the claims payment?

Insured PersonClaimant
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 Hour:Minutes

Place of damage

Reason and purpose of the stay at the place of damage

Description of the damage

Is it your fault?

YesNo
Reason

Is there fault on the part of a third party?

YesNo

Did the injured party contribute to the damage?

YesNo
Reason

Witness

Given name

Family name

Street

Country

ZIP Code

Town

Telephone

Witness email

Police notification

YesNo
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

with you on hirewith a crewmember on hirewith you on loanin your property

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?

YesNo
What damage if any?

Is repair possible?
YesNo
Time for repair:

Repair costs:

Where can damaged items be inspected?

Your opinion:

In case of bodily injury:

YesNo
Nature and extent of the injury

Claims of the injured party

YesNo
How much EUR?

YesNo
Why?

Have you already settled the damage to the injured party?

YesNo
If applicable, in which amount and currency:

Additional documents / attachments

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