Date of Birth
Did the injured person have any other accident insurance at the time of accident (if applicable via employer, sports club, trade union etc.)?
Yes, another insurance policy exists.
Please inform us about the insurance company, the policy number and the type of insurance
No, I don't have another insurance
Unless your bank is located in the European Union, please also provide address and SWIFT code of the bank.
Place of damage
Reason and purpose of the stay at the place of damage
What kind of sport did you practise when the accident occurred?
Detailed description of the accident:
Is it your fault?
Is there fault on the part of a third party?
Did the injured person drink alcohol within 24 hours prior to the accident?
If so, what kind and how much?
Was an alcohol blood sample taken?
Journal number/ File number
Does the injured person suffer from any illness or has the injured person had any accident in the past?
Has this resulted in invalidity, pension or inability to work?
If so, what kind?
Who was driving the boat at the time of the accident? (name, address)
What was the intention of the trip?
Length in feet:
Rented where? Name and address:
By sending this form I confirm the correctness of my data.