Claims registration - Third party liability damage

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Claims registration

Please complete your damage report

Third party liability damage (not caused by motor vehicle)

Responsible person

Company

Surname*

First name*

Telephone number*

Email*

IBAN or PC number

Subject to VAT YesNo

Claims data

Date of damage or when a problem was first detected*

Location of damage (address)*

How did the damage occur*

Injured parties

1. party (name and address)

2nd party (name and address)

3rd party (name and address)

Damage to or destruction of third party property/Claims from third parties

Describe the extent of the damage/defect as far as possible

Type of damage

Estimated amount of damage in CHF

Existing claims in CHF

Description of damaged property or other claims

Age of the damaged item

Additional remarks

Cause of damage

Fault on your part or on the part of your employees YesNo

Remarks

Fault of a subcontractor YesNo

Remarks

Fault of the injured party YesNo

Remarks

Fault of third party/other business person YesNo

Remarks

Additional remarks

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)

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