Notice of claim - Liability

Please fill out the questionnaire to indicate your claim.

Insuranceholder

First name

Last name

Street and Number

Country

ZIP code

City

Phone number

Faxnumber

Email address

Are you "Vorsteuerabzugsberechtigt"?

Insurancenumber

Damagedata

Date of damage

Time of damage

Damageplace and Street

Circumstances of damage

Type of damage

Was a vehicle involved?

Licence-plate-number

Which parts were damaged?

Data of Causer

First name

Last name

Age

Injured Person

First name

Last name

Street and Number

Country

ZIP code

City

Phone number

Faxnumber

Email address

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