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Comprehensive insurance and liability insurance Damage

Name and Address of the Insured:

Family nameGiven name
Street
ZIP Code, Town, country/state

Date of Birth

Family Status

Insurance Police no.

Job

Accessibility telephone
Email

Reason and purpose of the stay:

VDWS SafetyTool / Card:
where completed? (Name und Address)

 

INSTRUCTIONS:

1. For hull loss of rented material: Please refer to information sheet “How to act in case of damage”.

2. For damage to property and persons (third party): Please avoid any negotiation with the claimant. You are neither authorized to accept nor to settle the claim unless you are instructed by the insurer. Received documents (especially claiming letters, damage proofs, actions, court orders, application for legal aid etc.) have to be passed on to the insurer in original and without any delay. Enter an objection against court orders and file a protest against the enforcement measures!

Please observe that any insurance claim has to be announced without delay but within one week at the latest. If the claimant raises a claim you are obliged to inform the insurer within one week.

 

Details of the damage:

Date of incident
Time
Town, country/state

Description of the damage

 

Full name of third party concerned (Injured party):

Family name
Given name
Company name
Street
ZIP Code, Town
country/state
Accessibility telephone
Email
Beruf/ Accessibility telephone

Is the claimant authorized to deduct input tax
Yes  No

Are you related to the claimant
Yes  No

Do you live in a common household with the claimant
Yes  No

Do you have an employment contract with the claimant?
Yes  No

 

Material damage of claimant:

Which items were damaged?
(Please specify item, manufacturer, model No., year of manufacture)

 

Did you recognize any existing damage at the material?

Yes  No

If yes, please specify the damage(s)?

 

Kind and extent of damage:

Can it be repaired? Yes  No

Time for repair
Charges for repair
Year of purchase
Purchase price

 

Were the damaged items with you

on hire? Yes  No

on loan? Yes  No

in safekeeping? Yes   No

 

Where can the damaged items be examined?

 

Your evaluation:

Are you guilty?

Yes  No

Reason

Is there any guilty of the claimant?

Yes  No

Reason

Witnesses:

Police notification

Yes  No

address/department:

Journal No. / File No:

 

 

Physical injury of third party:

If a physical injury of the insured person occurred please fill in the form „accident report“.

Please answer the following question if the physical injury occurred at the claimant:

Medical treatment provided

Yes  No

stationary  ambulant

Type and extent of injury

 


Claims by the injured party

Have the claims already been notified against you?

No  Yes, verbally  Yes, in writing

How much?
EUR

 

Do you think that the demands of the injured party are acceptable?

Yes  No, why?

 

Have you already settled the damage to the injured party?

Yes  No     which amount and currency
Amount Currency

 

Do you have a private liability insurance?

Yes  No

If yes please indicate insurer and policy No.

if not available please hand in later.

 

To whom should the compensation be paid?

(family name and given name, company name)

Account number, bank code (IBAN/ BIC)

 

I certify by signing below that all the questions in this claims form have been answered fully and correctly. This also applies even if I did not write the answers by myself. I understand that knowingly supplied incorrect or incomplete details may lead to loss of insurance protection, even when this has no effect on the evaluation of the case, and do not thereby result in any injury for the insurer.

DON`T FORGET: Enclose documents and proofs relating to the claim! Only claims with complete documentation can be examined and settled. If the documents and proofs are not handed in within three weeks the claim will be put down without settlement. If you hand in further documents please always indicate in the subject heading the first and last name of the insured person.

In case of “comprehensive insurance” (damage of rented equipment) please furnish us with the following documents and invoices:

  • claim form

  • photo(s) of the damaged item(s)

  • purchase invoice, invoice of repair
    (The claimant can send the purchase invoice directly to Südwestring Versicherungsmakler GmbH.
    E-Mail: safetytool@suedwestring.de.
    Important: Please mention the name of the insured person in the subject heading!)

  • copy of hire contract

In case of general liability insurance (third party) please furnish us with the following documents and invoices:

  • claim form

  • photo(s) of the damaged item(s)

  • purchase invoice, invoice of repair
    (The claimant can send the purchase invoice directly to Südwestring Versicherungsmakler GmbH.
    E-Mail: safetytool@suedwestring.de.
    Important: Please mention the name of the insured person in the subject heading!)

If you press the button “send” you can still enclose the necessary documents.

Yes, I have read the privacy protection and agree to them.