PET 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)

    Phone (work)

    Damaged Party

    First Name

    Last Name

    Street

    ZIP Code, City

    Phone (private)

    Email

    Are you related to the damaged party?YesNo

    How are you related?

    Does the damaged party live in a domestic community with you?

    Claim Information

    Which of the insured pets (allegedly) caused the damage?

    Breed and Age of your Animal:

    Shoulder Height of your Animal:

    For how long have you owned the animal?

    When did the incident occur?

    Date

    Hour

    Minute

    Where did the incident occur?

    Street

    ZIP Code, 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:

    Were there any witnesses?YesNo

    Witness' Name

    Witness' Address

    Street

    ZIP Code, City

    Was the damage caused by the damaged party and is the damaged party at fault?YesNo

    Please give details why:

    Who else has, if only partially, caused the damage?

    Who was in charge of the animal at the time of the accident?

    Did this person observe the general duty of care?YesNo

    Is there any occupational/commercial purpose of the animal?YesNo

    Do dogs have to be on a leash at the place where the incident occured?YesNo

    Do dogs have to wear a muzzle at the place where the incident occured?YesNo

    Was your dog on a leash at the time of the incident?YesNo

    Was the other dog on a leash at the time of the incident?YesNo

    Breed of the other Dog:

    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

    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

    Is there any personal damage?YesNo

    Name of Injured Parties

    Address

    Street

    ZIP Code, City

    Age of Injured People

    Relationship StatusSingleMarriedDivorcedWidowed

    Kind of Injury

    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.