Claim details
Home Insurance Bllota
Policy Number
Please insert the policy number from your contract
E-Mail
Phone Number
Format: (000) 000-0000.
Name
*
Adress of the Insured
Straße und Hausnummer (zweite Zeile)
Location where the incident occured (if not at the adress of Insured)
When did the incident happen?
-
Tag
-
Monat
Jahr
Give brief details of the nature and cause of loss.
Give brief details of the property lost or damaged.
Estimated amount of loss or damage.
Please name the estimated salvage value.
Estimated amount of loss or damage.
Please name the estimated salvage value.
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Police report, Receipts
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Was the Fire brigade called? If NO, please describe the reason
*
Yes
No
Was the Police called? If NO, please describe the reason
*
Yes
No
Are you the sole owner of the property lost or damaged? If NO, give particulars of any other interest in the property.
*
Yes
No
Is there any existing insurance, whether affected by the claimant/or any other person on the said property? If YES, give brief details, including name of Insurer, policy number and amount insured.
*
Yes
No
Datum
-
Tag
-
Monat
Jahr
Datum
SUBMIT FORM
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