RENTERS 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*

    Time

    HH*

    MM*

    Where did the incident occur?

    Street*

    ZIP Code, City*

    Exact Location in the Building*

    Please describe what happened*

    Were there any witnesses?**YesNo

    Witness' Name

    Witness' Address

    Street

    ZIP Code, City

    Has the police taken down the incident?*YesNo

    Please state the file number:

    Address of the Police Station/Investigating Authorities:

    Which goods have been damaged/stolen? (Please also indicate manner and extent of the damages)

    In which condition were the damaged/stolen goods?*NewOldWell-MaintainedFaulty

    Age and Purchase Price of damaged Goods in EUR:

    Can the damage be repaired?*YesNo

    Estimated Costs of Repair

    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.