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License plate Please enter the full official license plate.

Type of license plate

Seasonal license plate from Month from (only relevant for seasonal license plates).

Seasonal license plate until Month until (only relevant for seasonal license plates).

Type of vehicle What type of vehicle is it?

Vehicle Manufacturer

Vehicle Model

HSN / TSN Manufacturer Key Number / Type Key Number.

Vehicle designation (plain text) Alternative plain text if HSN/TSN is not available.

Is it an electric or hybrid vehicle?

yes

Are the vehicle's batteries rented?

yes

Relevant only for electric or hybrid vehicles.

Remarks for more precise classification e.g. maximum speed, number of seats, special vehicle features.

Estimated Market Value (€)

Is the Vehicle Leased or Financed by Credit?

Loan financing term (months) Relevant only if financed by credit.

Year of construction

Vehicle's first registration

Registration in the name of the policyholder?

yes

Zustandsnote des Fahrzeugs (1 = sehr gut; 6 = schlecht)

Estimated annual mileage (km)

Current Odometer Reading (km)

Are special equipment installed in the vehicle?

yes

Description of special equipment and valuables Please provide a detailed description and individual/total values of special equipment.

Regular and predominant parking location

Parking space (other) Fill in only if the parking space is not a (underground) garage.

Is the vehicle used for everyday driving?

yes

Do you use additional comparable vehicles?

yes

Do you have driving experience with comparable vehicles?

yes

Driving experience since Fill in only if driving experience with comparable vehicles exists.

Are there any special or unusual risk situations?

yes

e.g. special use or parking conditions.

Description of special or unusual risk situations Please only fill out if special or unusual risk situations exist.

Vehicle owner (name as per vehicle registration)

Gender of vehicle owner

Date of Birth of Vehicle Owner

Is the Policyholder also the Owner?

yes

Name of Policyholder (if not Owner)

Gender of policyholder (if not owner)

Date of Birth of Policyholder (if not Owner)

Is Vehicle User also the Policyholder?

yes

Name of Vehicle User (if not Policyholder)

Date of Birth of Vehicle User (if not Policyholder)

Additional persons (additional vehicle users)

Professional status of the policyholder

Industry of the policyholder e.g. construction, tourism, agriculture, chemical industry, etc.

Negative entries in business credit files present?

yes

e.g. Creditreform, Infoscore, SCHUFA. Possibly explanation (e.g. personal bankruptcy).

Information on negative entries Fill in only if negative entries exist.

Is it a pure exhibition piece (no driving)?

yes

Are only (classic car) events attended with the vehicle?

yes

Usage of the vehicle

Are trips made outside Germany?

yes

Trips outside Germany – duration and countries Fill in only if trips outside Germany are undertaken.

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

yes

Information on use on race tracks Fill in only if the vehicle is driven on race tracks.

Hinweis: Dieser Abschnitt entfällt, sofern der Versicherungsschein des Alltagsfahrzeugs als Anlage beigefügt wird.

License plate of the everyday vehicle

Manufacturer/Model of the Everyday Vehicle

Manufacturer Number (Everyday Vehicle)

Type Key Number (Everyday Vehicle)

Insurance Certificate Number of Everyday Vehicle

Insurance Company of Everyday Vehicle

Previous insurance / previous damages

vorhanden

not available

Please indicate whether prior insurance and/or previous damages exist.

Previous insurance – Company

Previous Insurance – Contract Number

Termination by

Liability – no-claims discount (NCD) class

Liability – NCD valid since year

Partial coverage – deductible (€)

Comprehensive – Deductible (€)

Comprehensive – No-claims class (SF)

Comprehensive – SF valid since year

All-Risk Coverage Available?

yes

Have there been any prior damages in the last 5 years?

yes

Information on prior damages in the last 5 years Please specify the type of damage, date, and amount.

Annual Premium per Current Contribution Statement (€)

Is a seasonal license plate desired?

yes

Duration of the seasonal license plate Fill in only if a seasonal license plate is desired.

Scope of future insurance coverage

Liability

Partial coverage

Comprehensive Insurance

All-Risk Coverage

Multiple selection possible.

Desired deductible for partial coverage (€) Fill in only if partial coverage is desired.

Desired deductible for comprehensive coverage (€) Fill in only if full coverage is desired.

Desired insurance value

Payment method

Is additional insurance coverage desired?

yes

Type of Additional Insurance Coverage

Driver protection

Protection letter

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

yes

Attached documents (attachments)

Copy of registration certificate part I

Current Photos (Exterior, Interior, Engine Compartment, Trunk)

Valuation report (not older than 2 years)

Purchase invoice

Insurance Certificate of Everyday Vehicle

Other notes and 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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PRIVATE - Risk assessment classic cars