Given name
Family name
Street
Country
ZIP Code
Town
Phone number
Email
Date of Birth
Job
relationship to the insured person
Does a contract with another insurance company exist for this claim (e.g. personal liability, hull, skipper’s liability, travellers' baggage, household contents 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?
Yes No
Do you live in a common household with the claimant?
Do you have an employment contract with the claimant?
Who shall receive the claims payment?
Insured person claimant
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
Loss date
Time
Place of damage
Reason and purpose of the stay at the place of damage
Description of the 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:
Is the damaged item:
with you on hire? with you on loan? in your property? in your custody / care?
Where can the damaged items be inspected?
Is it your fault?
Reason
Is there fault on the part of a third 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:
By sending this form I confirm the correctness of my data.
Required field
