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File a Claim
Claim Form – Pet Liability
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?
Yes
No
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
AM/PM
AM
PM
Where did the incident occur?
Street
ZIP Code, City
Please describe what happened
Has the police taken down the incident?
Yes
No
Please state the file number:
Address of the Police Station/Investigating Authorities:
Were there any witnesses?
Yes
No
Witness' Name
Witness' Address
Street
ZIP Code, City
Was the damage caused by the damaged party and is the damaged party at fault?
Yes
No
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?
Yes
No
Is there any occupational/commercial purpose of the animal?
Yes
No
Do dogs have to be on a leash at the place where the incident occured?
Yes
No
Do dogs have to wear a muzzle at the place where the incident occured?
Yes
No
Was
your dog
on a leash at the time of the incident?
Yes
No
Was
the other dog
on a leash at the time of the incident?
Yes
No
Breed of the other Dog:
Is there any property damage?
Yes
No
Which third-party goods have been damaged? (Please also indicate manner and extent of the damages?
In which condition were the damaged goods?
New
Old
Well-Maintained
Faulty
Age and Purchase Price of damaged Goods in EUR:
Can the damage be repaired?
Yes
No
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?
Yes
No
Has the use of the damaged good been permitted?
Yes
No
Is there any personal damage?
Yes
No
Name of Injured Parties
Address
Street
ZIP Code, City
Age of Injured People
Relationship Status
Single
Married
Divorced
Widowed
Kind of Injury
Profession and Employer of Injured Person
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.
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