Claims registration - Damage involving motor vehicles

Claims registration

Please complete your damage report

Damage involving motor vehicles (licence plate available)

Responsible person

Company

Surname*

First name*

Telephone number*

Email*

IBAN or PC number

Subject to VAT YesNo

Driver

Surname

First name

Street and number

Postcode

Town/city

Date of birth

Driving licence held since

Claims data

Date of damage*

Location of damage (address)*

How did the damage occur*

Own vehicle (make and type)

Vehicle

License plate

If property damage to own vehicle

What was damaged?

Damage amount

Who are you commissioning to carry out the repair?

When? (planned repair)

Notes

In the event of damage to third-party property/vehicles

What was damaged?

Vehicle of the injured party

Name of the injured party

Address of the injured party

Notes on damage to other people's property

Do you consider yourself responsible for the accident?

In the case of personal injury

First name

Surname

Nature of the injury

Name of the doctor

Notes on personal injury

Police report

Has a police report been made? YesNo

If yes: Police station, date of report and officer in charge

Miscellaneous

Remarks

Documents

Add enclosures to the notice of claim here (max. 5 MB per file)