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PRIVATE - Risk assessment motor vehicle insurance

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Schritt 1 von 7 Your Form Progress

Registration certificate enclosed

yes

License plate Fill in only if no copy of the registration certificate is attached.

Manufacturer Key Number Fill in only if no copy of the registration certificate is attached.

Type Key Number Fill in only if no copy of the registration certificate is attached.

What type is it?

Truck - Payload in tons

Power in kW (motorcycles only)

Power in HP (motorcycles only)

Remarks for more precise classification (maximum speed, seats, etc.) If this is a classic car, please use the classic car risk assessment.

Vehicle identification number

Date of First Registration

Date of Registration to Holder / Policyholder

Is it an electric or hybrid vehicle?

yes

Are the vehicle's batteries rented?

yes

Replacement value in €

Acquisition value in €

Time value in €

Is the Vehicle Leased / Financed by Credit?

geleast

kreditfinanziert

Lease / loan term in months

Does the vehicle have the following driver assistance systems etc.?

Lane Keeping Assist

Turning assistant

Adaptive cruise control

Emergency brake assistant

Dashcam

Have special equipment been (subsequently) installed in the vehicle? (e.g. navigation system, hi-fi system, ramps, cranes, etc.)

yes

Special equipment – detailed description and values

Estimated annual mileage in km

Current Odometer Reading in km

Regular and predominant parking location between 10:00 PM and 6:00 AM

The storage location is

absperrbar

Publicly Accessible

Usage

Is the Vehicle Recognized as a Business Expense?

yes

Are you entitled to input tax deduction?

yes

Should the proposal be optimized regarding young drivers (from 18)?

yes

Young Future Driver (Name, Date of Birth, etc.)

Is the purchase of a second or third vehicle planned?

yes

Planned second or third car (details)

Is a trailer or caravan towed with the vehicle?

yes

Information on trailer or caravan

Are there any further special and unusual risk situations that have not been explicitly asked about so far?

yes

Description of special and unusual risk situations

Policyholder – Name

Gender of policyholder

weiblich

male

Date of Birth of Policyholder

Date of Driver's License Acquisition (Policyholder)

Professional status of the policyholder

Industry in which the policyholder is employed

Who is the vehicle owner (according to the vehicle registration)?

Policyholder

anderer

Name of Vehicle Owner (if not Policyholder)

Do you (policyholder) own owner-occupied residential property?

yes

Type of Residential Property and Insurance Company

Do children live in your household?

yes

Number of children

Date of Birth of Youngest Child

Date of Birth of Oldest Child

Are you a member of an automobile club?

yes

Automobile Club and Membership Since

Are there negative entries in credit reporting files (e.g. Creditreform, Infoscore or SCHUFA) for the insured or owner?

yes

Exact details of negative entries (e.g. personal insolvency)

Vehicle User

Youngest User – Date of Birth

Youngest User – Date of Driver's License Acquisition

Oldest user – date of birth

Oldest user – date of driver's license acquisition

Additional information about vehicle users (name, date of birth, driver's license data; designation as policyholder/partner/child)

Which of the vehicle users participated in accompanied driving?

keiner

Details see additional notes

Are trips made to non-European foreign countries?

yes

Duration and countries for trips to non-European foreign countries

Is the vehicle driven on race tracks (except driver safety training)?

yes

Exact details of use on race tracks

License plate of the lead vehicle

Deregistration Date of Previous Vehicle

Second car regulation

yes

If yes, data on previous insurance (3.4) are omitted.

Previous insurance – Company

Previous Insurance – Contract Number

Termination of Previous Insurance by

Policyholder

Insurer

Liability – NCD class / year

Partial coverage – deductible in €

Comprehensive – Deductible in €

Comprehensive – SF class / year

Protection letter present in previous insurance

no / unknown

yes

Are the above NCDs a special classification?

yes (years are transferable)

Number, type and amount of prior damages in the last 5 years

none

Previous damages present

Details on number, type, and amount of prior damages in the last 5 years

Is a seasonal license plate desired?

yes

Duration of the seasonal license plate

Desired Scope – Liability (No Claims Bonus / Year)

Desired Scope – Partial Comprehensive (Deductible in €)

Desired Scope – Full Comprehensive (Deductible in €)

Desired Scope – Full Comprehensive (No Claims Bonus / Year)

Desired Scope – Roadside Assistance

yes

Please contact us if you wish to change the insurance coverage (e.g., conversion from comprehensive to partial coverage, change of use).

yes

How should the consultation take place if you do not contact us yourself?

Requested payment method

by invoice

by direct debit

Account holder

IBAN

Credit institution

Payment method

No-claims protection (claim does not affect no-claims class if no insurer change occurs)

yes

Mallorca Police (Increase of coverage amount for vehicles rented abroad)

yes

GAP coverage (assumption of the difference between current value and current lease residual value)

yes

Waiver of the Defense of Gross Negligence

yes

Replacement value compensation

yes

Secondary damage from marten bites

yes

Extended wildlife damage clause (collision with animals of all kinds)

yes

Driver accident protection

yes

Passenger Accident Insurance

yes

Foreign Damage Protection (No-fault Accident Abroad – Claim with Own Car Insurer)

yes

Protection letter (e.g. breakdown assistance and towing costs)

yes

Workshop binding

yes

Should accumulators, charging cables etc. be co-insured? (Electric or hybrid vehicles)

yes

Other special inclusions (e.g. purchase price compensation, direct settlement, own damage coverage, compensation for depreciation in repair damages, roof avalanches, braking, operational and breakage damages, extension of natural hazard damages, rental vehicles abroad, service update)

yes

Requested special inclusions (details)

Is additional insurance coverage desired? (e.g., accident, traffic legal protection, transport, disability, term life, long-term care, daily sickness allowance)

yes

What additional insurance coverage is desired?

Other notes, remarks

Bei den Fragen handelt es sich um Fragen über gefahrerhebliche Umstände. Unvollständige und unrichtige Angaben zu den gefahrerheblichen Umständen berechtigen den Versicherer, im Falle der vorsätzlichen oder grob fahrlässigen Verletzung der Anzeigepflicht, vom Versicherungsvertrag zurückzutreten. Wird die Anzeigepflicht vorsätzlich oder grob fahrlässig verletzt, hat der Versicherer das Recht, den Vertrag innerhalb eines Monats ab Kenntnis von der Anzeigepflichtverletzung unter Einhaltung einer Frist von einem Monat zu kündigen. Diese Daten werden ggf. zur weiteren Verarbeitung (z.B. Angebotserstellung, Schadenbearbeitung etc.), wie in der "Einwilligungserklärung zur Datenverarbeitung" beschrieben, an Versicherer und Dienstleister weitergeleitet.

Date

Customer's signature

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