PERSONAL LIABILITY CLAIM FORM

    Fill out this form in order to provide us with a detailed explanation of your case.

    Personal Information

    Name of Policy Holder*

    Policy Number*

    Street

    ZIP Code, City

    Phone (private)

    Email

    Damaged Party

    Name

    Street

    ZIP, City

    Phone (private)

    Phone (work)

    Are you related to the damaged party?YesNo

    How are you related?

    Claim Information

    When did the incident occur?

    Date

    HH

    MM

    Where did the incident occur?

    Street

    ZIP, City

    Which of the insured individuals (allegedly) caused the damage?

    Name

    Date of Birth

    Address

    Street

    ZIP, City

    Are you related to the person who caused the damage?YesNo

    How are you related?

    Were there any witnesses?YesNo

    Witness' Name

    Witness' Address

    Street

    ZIP, City

    Please describe what happened

    Has the police taken down the incident?YesNo

    Please state the file number:

    Address of the Police Station/Investigating Authorities:

    Is the person who caused the damage also at fault?YesNo

    In which regard?

    Was the damage caused by the damaged party and is the damaged party at fault?YesNo

    Who else has, if only partially, caused the damage?

    Has the damage been caused while the person who caused the damage carried out their professional activity?YesNo

    Has the person who caused the damage been working for payment for the damaged party?YesNo

    Did they act out of courtesy for the damaged party?YesNo

    Has the damaged party asked the person who caused the damage to assist them?YesNo

    Have you or the other person who caused the damage rented, leased or borrowed the damaged goods or were they part of a special safekeeping contract?YesNo

    Has the use of the damaged good been permitted?YesNo

    You are:

    Do you own a single-family house?YesNo

    Do you own a condominium?YesNo

    Do you own a multi-family house?YesNo

    Do you rent out a lodger flat?YesNo

    Number of rented-out rooms

    Do you rent out rooms?YesNo

    Number of rented-out rooms

    Is there a commercial enterprise on your premises?YesNo

    Is there any property damage?YesNo

    Which third-party goods have been damaged? (Please also indicate manner and extent of the damages?

    In which condition were the damaged goods?NewOldWell-MaintainedFaulty

    Age and Purchase Price of damaged Goods in EUR:

    Can the damage be repaired?YesNo

    Estimated Costs of Repair in EUR

    Is there any personal damage?YesNo

    Name of Injured Parties

    Kind of Injury

    Relationship StatusSingleMarriedDivorcedWidowed

    Address of Injured Parties

    Street

    ZIP, City

    Age of Injured People

    Profession and Employer of Injured Person

    If available, please upload relevant documents/images here:

    Important Advice

    Please fill in and return this claims report truthfully and completely. Deliberate or incomplete information can lead to the complete loss of the insurance benefit. Gross negligently untrue information can lead to a reduction of the insurance benefit proportional to the degree of your negligence unless this information is unnecessary for the determination of the insurance insured event or for the determination or the extent of our obligation to perform.