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:

    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.