RENTERS GLASS DAMAGE CLAIM FORM

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

    Personal Information

    Policy Number*

    Name of Policy Holder*

    Street*

    ZIP Code, City*

    Phone (private)

    Email*

    Damaged Party

    Name*

    Street*

    ZIP Code, City*

    Phone (private)*

    Phone (work)

    Claim Information

    When did the incident occur?

    Date*

    Hour

    Minute

    Where did the incident occur?

    Street*

    ZIP, City*

    Exact Location in the Building*

    Were there any witnesses?YesNo

    Witness' First Name

    Witness' Last Name

    Witness' Address

    Street

    ZIP, City

    Please describe what happened*

    What type of damage did occur?*BreakCrackChipScratchOther

    What type of glass was damaged?*Single Glass PaneSafety GlassInsulation GlassOther

    What type of frame did the glass have?

    Is it a ceramic stove that is damaged?*YesNo

    Make & Model:

    Can the stove top be changed?YesNo

    In which condition was the damaged glass?*NewOldWell-MaintainedFaulty

    Age and Purchase Price of the damaged Glass in EUR:

    Has the police taken down the incident?*YesNo

    Please state the file number:

    Address of the Police Station/Investigating Authorities:

    Did a third party cause the damage?*YesNo

    Name of the Third Party

    Address of the Third Party

    Street

    ZIP, City

    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.