CAR DAMAGE CLAIM FORM

Before you submit your claim, check out the:

4 USEFUL TIPS TO A SPEEDY CLAIMS PROCESSING
1. Your Accident Report

Fill out every space as completely as possible. In your description of “What Happened”, please include the road conditions, time of day, weather conditions, what property may have been damaged, injuries and contact details of the opposite party and the info of their insurance, as well as, anything and everything else that concerns the incident.

2. Customers with LRP (Loyalty Repair Program)

Check out our Loyalty Repair Program that will provide you – in each case agreed with us – with a loaner car free of charge for up to 21 days (except total loss cases). In case you have no LRP incl. you can contact us and ask for advice.

3. Please send us a copy of the MP report / Polizei-Report

Please note that this report is required for every claim if a third party is involved or other property has been damaged.

4. Authorization by your Lien holder

If there is a lien on your vehicle, the lien holder is formally entitled to all compensation payments. Also, the lien holder is required to be involved in the claims management procedure.

Please call your agent if you have any questions!

    Fill out this form in order to provide us with a detailed explanation of your case.

    Personal Information

    Name of Policy Holder*

    Policy Number*

    Email*

    Phone Number*

    Vehicle Information

    Year, Make, Model*:

    License Plate Number*:

    Mileage*

    Is your vehicle damaged?*YesNo

    Where is the damage?

    What are the estimated repair costs in EUR, if known?

    Is your vehicle still driveable?YesNo

    Where is the vehicle now?

    Have there been any damages to your vehicle prior to this incident?*(whether repaired or not)?YesNo

    Who did finance your vehicle? (lien holder):

    Lien holder phone number:

    Lien holder fax number:

    Accident Information

    Accident Location Address*

    Accident Location Address (further specs)

    City*

    Postal / Zip Code*

    Country*

    When did the accident happen?*

    What time did the accident happen at?*

    HH

    MM

    AMPM Central Europe Time (CET)

    Who was driving?*

    Driver's date of birth:*

    Driver's license number:*

    Has the accident been reported to the MP or German police (Polizei)?*YesNo

    If available, paste or upload the police report here

    Were you driving under the influence of alcohol?*YesNo

    Were you driving under intoxication of drugs?*YesNo

    Claimant Information

    Are there any witnesses to this accident?*YesNo

    Please provide us with the witness(es)'s contact information

    Was there anybody else involved in the accident?*YesNo

    Please provide the third party's information

    Name, First Name

    Street, No.

    ZIP Code, City

    Phone No.

    Email

    License Plate

    Make, Model

    Where is the damage?

    Do you know where the vehicle is insured?

    Is this person claiming against your insurance?*YesNo

    Did this person drive under intoxication of alcohol or drugs (DUI)?*YesNoDon't Know

    Did you hit anything else? (e.g. a guard rail)?*YesNo

    What did you hit?

    Is it damaged?

    Are there any injured third parties?*YesNo

    Please provide us with the injured party's contact information

    Do you think the accident was caused by yourself?*YesNo

    Would you like to make a claim for your own damage?*YesNo

    Please give us a short description of what happened:*

    Upload pictures of the accident scene and damages. (Limit up to 3 files, 5MB each.)

    Please confirm your information:*I confirm the duty of truthfulness**

    Data Processing:*

    If you have any further questions, please call our claims department: +49 221 925488-78.

    **DUTY OF TRUTHFULNESS

    Dear customer, please be advised that if you do not give us truthful information with deliberate intention or no information at all or do not make the respective bills and receipts available to us, you will lose your entitlement to your insurance benefit. If you violate these obligations in a grossly negligent manner you will in fact not lose your entitlement completely but we can cut our benefits in relation to the severity of your fault. The benefits will not be cut if you can prove that the obligation was not violated in a grossly negligent manner. If you violate the obligation for information or support or for the delivery of bills and receipts fraudulently, no actions shall lie against the insurance company.