Claim form for private customers

First name, surname: *
Street, house number:
Postcode, city:
Telephone number:
Insurance company:
E-Mail: *
Insurance number:
Which insurance company would you like to report a claim to?Placeholder
Insurance:
Other:
Type of damage:Placeholder
Damage:
Other:
Details of the damage:Placeholder
Date of damage:
Time of day:
Amount of loss in euros:
Injured party in the event of liability claims:Placeholder
Name:
address:
Loss location:Placeholder
Street:
Postcode, city:
Placeholder
Brief description of damage *
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* Pflichtfeld