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)
Phone (work)
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:
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.