Company ? this is an info

Address

Contact person – Name

Contact person – Email Contact for queries regarding the claim. The form link is only sent via the explicitly triggered dispatch function.

Contact person – Phone

Claimant – Name / Company

Claimant – Address

Claimant – Email

Claimant – Phone

What is the traffic order given to you? Please only specify in keywords if the order was given orally; otherwise please attach the order.

Attach Traffic Order (if available)

Applicable / Agreed Liability Basis

Foreign Law (Which?) Only if foreign law was chosen.

Name/address of the client

Name/address of the executing carrier/causer

Departure Location

Destination

Time of takeover (day, time) Select or enter date and time, e.g. 10/04/2026 14:30.

Time of delivery (day, time) Select or enter date and time, e.g. 10/04/2026 14:30.

Was a delivery date agreed upon?

Did the recipient issue an unconditional receipt?

Receipt issued on Please select… Waybill Freight forwarding order / handover note Delivery note Roll card / bordero Only if an unconditional receipt was issued.

Type of Damage

Estimated damage amount (amount in €)

Which item is missing or damaged?

How was the item packaged?

When did you discover the damage?

How was the damage reported to you?

Damage reported on (date, time) Select or enter date and time, e.g. 10/04/2026 14:30.

Attach written damage report (if available)

Where is the damaged property located?

Detailed account of the damage (type, cause and extent)

Shipment Scope – Total Number of Packages Total number of all packages in the shipment, including undamaged packages.

Type of packages (e.g. boxes, pallets, buckets) Enter packaging type, not quantity. The number of damaged or lost packages is recorded separately.

Shipment Scope – Total Weight (kg)

Damaged/lost packages – quantity Only damaged or lost packages count.

Damaged/lost packages – weight (kg)

Has a police report been filed?

To which police station was the damage reported?

Police – File Number / Diary Number

Police – Reported When? (Date, Time) Select or enter date and time, e.g. 10/04/2026 14:30.

Police – Full Address

Do you have any objections to the claim?

Objections to the claim – which ones? Only if objections exist.

Was the damage amount deducted from the freight?

Has an ADS cargo insurance been applied for by the client/covered by you?

Sum Insured (€)

Calculated premium (€)

Registration month

How should the payment be made?

Institute Only if payment should be made to the following account.

Account Only if payment should be made to the following account.

BLZ Only if payment should be made to the following account.

Account holder Only if payment should be made to the following account.

Are you entitled to deduct input tax under the German VAT law?

City

Date

Signature of the policyholder