PERSONAL 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)
Email
Damaged Party
Name
Street
ZIP, City
Phone (private)
Phone (work)
Are you related to the damaged party?YesNo
How are you related?
Claim Information
When did the incident occur?
Date
HH
MM
Where did the incident occur?
Street
ZIP, City
Which of the insured individuals (allegedly) caused the damage?
Name
Date of Birth
Address
Street
ZIP, City
Are you related to the person who caused the damage?YesNo
How are you related?
Were there any witnesses?YesNo
Witness' Name
Witness' Address
Street
ZIP, 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:
Is the person who caused the damage also at fault?YesNo
In which regard?
Was the damage caused by the damaged party and is the damaged party at fault?YesNo
Who else has, if only partially, caused the damage?
Has the damage been caused while the person who caused the damage carried out their professional activity?YesNo
Has the person who caused the damage been working for payment for the damaged party?YesNo
Did they act out of courtesy for the damaged party?YesNo
Has the damaged party asked the person who caused the damage to assist them?YesNo
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
Do you own a single-family house?YesNo
Do you own a condominium?YesNo
Do you own a multi-family house?YesNo
Do you rent out a lodger flat?YesNo
Number of rented-out rooms
Do you rent out rooms?YesNo
Number of rented-out rooms
Is there a commercial enterprise on your premises?YesNo
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 in EUR
Is there any personal damage?YesNo
Name of Injured Parties
Kind of Injury
Relationship StatusSingleMarriedDivorcedWidowed
Address of Injured Parties
Street
ZIP, City
Age of Injured People
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.