Damage report third party liability

Insured person

Given name

Family name

Street

Country

ZIP Code

Town

Phone number

Date of Birth

Job

Co-insured person (Information only required in SafetyTool Plus and insofar as this person has caused the damage)

Given name

Family name

Street

Country

ZIP Code

Town

Phone number

Date of Birth

Job

relationship to the insured person

Information about your insurance

Does liability insurance with another insurance company exist (e.g. personal liability, boat iability, skipper’s liability insurance etc.)?

Yes, another insurance exists

Please inform us about the insurance company, the policy number and the type of insurance

No, I don’t have another insurance.

No, the rental station/ charter operator/ boat doesn’t have another insurance.

Information on the claimant

Given name

Company name / family name

Street

Country

ZIP Code

Town

Phone number

Are you related to the claimant?

Yes
No

Do you live in a common household with the claimant?

Yes
No

Do you have an employment contract with the claimant?

Yes
No

Is the claimant a crew member?

Yes
No

Who shall receive the claims payment?

Insured person
claimant

Bank

IBAN

BIC

Unless your bank is located in the European Union, please also provide address and SWIFT code of the bank.

Bank details for the transfer of insurance payments

SWIFT

Description of the damage:

Loss date

Time

Place of damage

Reason and purpose of the stay at the place of damage

Description of the damage:

Is it your fault?

Yes
No

Reason

Is there fault on the part of a third party?

Yes
No

Did the injured party contribute to the damage?

Yes
No

Reason

Witness

Given name

Family name

Street

Country

ZIP Code

Town

Phone number

Police notification:

Yes
No

address/department:

Journal number/ File number

In case of accidents while sailing or driving a motorboat, please also answer to the following questions:

Was the boat you lead

with you on hire?
with a crewmember on hire?
with you on loan?
in your property?

In case of property damage:

Damaged item (manufacturer, type, size)

year of acquisition:

Purchase price:

Serial number:

Was there any noticeable previous damage to the damaged material?

Yes
No

What damage, if any?

Is repair possible?

Yes
No

Time for repair:

repair costs:

Where can the damaged items be inspected?

Your opinion:

In case of bodily injury:

Medical treatment:

Yes
No

Nature and extent of the injury:

Claims of the injured party

Have claims already been asserted against you?

Yes
No

How much? EUR

Do you consider the injured party's claims to be reasonable?

Yes
No

Why?

Have you already settled the damage to the injured party?

Yes
No

If applicable, in which amount and currency:

Additional documents / attachments

By sending this form I confirm the correctness of my data.

Required field