Damage report accident

Insured person

Given name

Family name

Street

Country

ZIP Code

Town

Phone number

Date of Birth

Job

Information about your insurance

Did the injured person have any other accident insurance at the time of accident (if applicable via employer, sports club, trade union etc.)?

Yes, another insurance policy exists.

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

No, I don't have another insurance

Bank details for the transfer of insurance payments

Bank

IBAN

BIC

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

Description of the damage:

Loss date

Time

Place of damage

Reason and purpose of the stay at the place of damage

What kind of sport did you practise when the accident occurred?

Detailed description of the accident:

Is it your fault?

Yes
No

Reason

Is there fault on the part of a third party?

Yes
No

Reason

Medical report and diagnosis:

Did the injured person drink alcohol within 24 hours prior to the accident?

Yes
No

If so, what kind and how much?

Was an alcohol blood sample taken?

Yes
No

Result

Police notification:

Yes
No

address/department:

Journal number/ File number

Does the injured person suffer from any illness or has the injured person had any accident in the past?

Yes
No

Has this resulted in invalidity, pension or inability to work?

Yes
No

If so, what kind?

In the case of damage occurring in connection with the use of a sailing or motor boat:

Who was driving the boat at the time of the accident? (name, address)

What was the intention of the trip?

Information about the boat:

Manufacturer:

Type/ model:

Length in feet:

Hp/kW:

Rented where? Name and address:

Additional documents / attachments

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

Required field