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Customer (display)

Custom Label

Different date (optional) ?

Insurance Number

Insurance company

Options

Please provide us with the claim number.

Information on Settlement Requested

Correspondence to policyholder

Correspondence to insurance broker

1.1. Assignment?

1.2 Client?

1.3. Sender?

1.4. Recipients?

1.5. Claimants?

2.1. Means of Transport

PKW

Car station wagon

LKW

Trailer

Tractor unit with semi-trailer

2.2 Official license plate

2.3. zulässiges Gesamtgewicht / Nutzlast

Total weight (kg)

Payload (kg)

2.4 Vehicle Body

Tarpaulin

Suitcase

Cool

Tank

2.5. License number, valid until, location

2.6. Name of driver and passenger

Departure – date and time Select date in calendar; set time below via hour and minute or enter directly as DD.MM.YYYY HH:MM.

Arrival – date and time Select date in calendar; set time below via hour and minute or enter directly as DD.MM.YYYY HH:MM.

2.8. Orte

Departure Location

if applicable, transshipment to

Destination

2.9. Loading by

Driver

Driver on behalf of sender

Sender

2.10. Unloading by

Driver

Driver on behalf of recipient

Recipient

2.11. Quantity checked by driver according to freight documents?

yes

2.12. Content of the loading unit checked upon takeover?

yes

2.13. Transport goods externally damaged upon takeover?

yes

Wenn ja: Art der Beschädigungen

2.14. Reservations noted in freight documents?

yes

2.15. Agreed liability

AGB

HGB

CMR

none

3.1. Schadentag / -uhrzeit

Date of Damage

Time

3.2 Transport goods / packaging / damage weight (kg)

3.3. Value of goods before damage (specify owner of goods) in €

3.4. Type of damage

Shortage quantity

Damage

3.5. Damage occurrence at

Transport

Unloading

Interim storage

unbekannt

3.6. Damage assessment at

Transport

Unloading

Interim storage

after delivery

3.7. Has the recipient granted "pure quality"?

yes

Document

Waybill

Freight handover note

Delivery note

Roll card

CMR Consignment Note

3.8. Has the driver confirmed the reservation (damage/loss) with a signature?

yes

3.9. How did the damage occur?

3.10. Fixed delivery date agreed?

yes

3.11. Zeitpunkte

Takeover Time Select date in calendar; set time below via hour and minute or enter directly as DD.MM.YYYY HH:MM.

Delivery Date Select date in calendar; set time below via hour and minute or enter directly as DD.MM.YYYY HH:MM.

agreed delivery date Select date in calendar; set time below via hour and minute or enter directly as DD.MM.YYYY HH:MM.

3.12. Location of inspection of damaged items

3.12. Loss adjuster involved?

yes

Wenn ja: Name, Anschrift, Telefon, Fax, Mail

3.13. Police: Report filed?

yes

Dienststelle, Datum, Aktenzeichen

3.14. Objections to the claim raised?

yes

If yes: which?

3.15. Damage amount already deducted from freight?

yes

Wenn ja: wann?

3.16. Auszahlungskonto (für eventuelle Entschädigung)

Account

at (bank)

BLZ

IBAN

Account holder

3.17. Attached to this damage report are

Freight Documents

Delivery invoice

Damage Invoice

Police Confirmation

Driver's Takeover Receipt

Recipient's Takeover Receipt

General Terms and Conditions

4.1. Preferred Contact Method

Phone

sonstiges

4.2. Contact details (email, phone, mobile etc.)

4.3. Best availability (time window, business hours)

Remarks

Duty Notice

I/we commit to immediately notify the company if stolen or lost items are found again or if I/we learn more about the perpetrator or the whereabouts of the items.

Obligation

All questions must be answered completely and correctly to the best of your knowledge. Intentional or grossly negligent violations may lead to (partial) loss of insurance coverage.

Explanation

I have answered the above questions truthfully. I agree to the payment of any compensation to the claimant.

Traffic Liability Damage Report