RENTERS GLASS DAMAGE CLAIM FORM

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)
Email
Damaged Party
Name
Street
ZIP Code, City
Phone (private)
Phone (work)
Claim Information
When did the incident occur?
Date
Hour
Minute
Where did the incident occur?
Street
ZIP, City
Exact Location in the Building
Were there any witnesses?YesNo
Witness' First Name
Witness' Last Name
Witness' Address
Street
ZIP, City
Please describe what happened
What type of damage did occur?BreakCrackChipScratchOther
What type of glass was damaged?Single Glass PaneSafety GlassInsulation GlassOther
What type of frame did the glass have?
Is it a ceramic stove that is damaged?YesNo
Make & Model:
Can the stove top be changed?YesNo
In which condition was the damaged glass?NewOldWell-MaintainedFaulty
Age and Purchase Price of the damaged Glass in EUR:
Has the police taken down the incident?YesNo
Please state the file number:
Address of the Police Station/Investigating Authorities:
Did a third party cause the damage?YesNo
Name of the Third Party
Address of the Third Party
Street
ZIP, City
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.