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:
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.