Customer (display)

Custom Label

Different date (optional) ?

Insurance Number

Insured Vehicle (License Plate)

Insurance company

Options

Type of damage

Type of damage – other (free text)

Vehicle financing

Mileage (km)

Previous damages to the insured vehicle?

Date of Damage

Time

Damage Location (Address)

Exact account of the damage event

Property damage – comprehensive insurance (documents)

Type of damage

Current Vehicle Location

Estimated Damage Amount (€)

Eligible for input tax deduction?

Bank Account – Account Number

Bank Account – at (Bank)

Bank Account – Bank Code

Bank Account – IBAN

Billing

Additional remarks

Additional information for comprehensive damage claims

Driver at Time of Incident

Driver (different) – name

Driver (different) – address

Was the trip approved by the policyholder?

Valid driving license available?

Driver's license class

Driver's license since when?

Issuing Authority

Restrictions/Conditions

Under the influence of drugs/alcohol?

If yes: Type & Examination Result

Trailer involved?

Trailer – license plate

Trailer – insurer

Trailer – policy number

Who caused the damage?

Responsible Party (Other) – Name

Responsible Party (Other) – Address

Responsible Party (Other) – Status

Witness – name

Witness – address

Police Report Filed?

If yes: authority & file number (protocol)

Investigation or Criminal Proceedings Initiated?

If yes: authority & file number (procedure)

Hit and run?

If yes: further details

Preferred Contact Method

Contact – Other (optional)

Contact Details for Processing (Email/Phone, etc.)

Telephone handling – availability (time window) ?

Broker's settlement recommendation

Settlement amount (€)

Payment to

Other notes / Addressee (free)

Note: Deliberately false or incomplete information can lead to loss of insurance coverage, even if no disadvantage arises for the insurer.

Place (signature)

Date (Signing)

Consent (Signature) ?