Please fill out your claim form

Claim forms

MotorVehiclesDamage

Responsible person

Surname(Required)

First name(Required)

Company(Required)

Telephone number(Required)

Emai(Required)

IBAN or PC number

Subject to VAT

Yes

Driver

Surname

First name

Street and number

Postcode

Town/city

Date of birth

Driving licence held since

Claims data

Date of damage or when a problem was first detected(Required)

Location of damage/address(Required)

How did the damage occur(Required)

Own vehicle (make and type)

Vehicle

License plate(Required)

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 (Address, E-Mail, Telephone)

Notes on damage to other people's property

Do you consider yourself responsible for the accident?

In the case of personal injury

Surname

First name

Nature of the injury

Name of the doctor

Notes on personal injury

Police report

Has a police report been made?

Yes

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

Miscellaneous

Remarks

Drop files here or

Max. file size: 5 MB, Max. files: 5.

(You can add up to five attachments here. You are welcome to submit any additional documents to schaden@verlingue.ch.)