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:

    Please confirm your information:*I confirm the duty of truthfulness**

    Data Processing*:

    If you have any further questions, please call our claims department: +49 221 925488-78.

    **DUTY OF TRUTHFULNESS

    Dear customer, please be advised that if you do not give us truthful information with deliberate intention or no information at all or do not make the respective bills and receipts available to us, you will lose your entitlement to your insurance benefit. If you violate these obligations in a grossly negligent manner you will in fact not lose your entitlement completely but we can cut our benefits in relation to the severity of your fault. The benefits will not be cut if you can prove that the obligation was not violated in a grossly negligent manner. If you violate the obligation for information or support or for the delivery of bills and receipts fraudulently, no actions shall lie against the insurance company.