CAR GLASS DAMAGE CLAIM FORM

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

    Name of Policy Holder*

    Policy Number*

    Email*

    Phone Number*

    Vehicle Information

    Year, Make, Model:

    License Plate Number*:

    Glass Damage Information

    When did the incident happen?*

    Where did the incident happen?*

    At what time did the incident happen?*

    Hour

    Minute

    (CET)

    Please give us a short description of what happened*:

    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.