Claim form for a motor vehicle/motorcycle accident

Transcription

1 Clai or or a otor vehicle/otorcycle accident To be copleted by ENNIA advisor policy. custoer. agent nae agent. nae advisor advisor. phone advisor phone agent clai. Policyholder private individual aily nae aiden nae, i arried initial(s) street house. country irst nae phone gender ax city / country o birth cell e-ail nationality bank arried single driver s license. 1) job legal entity / business / copany nae priary place o business sector o industry contact person 2) job living together bank account. occupation eployer phone ax e-ail website Trade reg.. Chaber o Coerce 3) Nae(s) o the person(s) who are stakeholders in relation to this copany Driver's details (i t the sae as the policyholder's) aily nae initial(s) irst nae street house. country driver s license. 4) 1,4) enclose a copy o the driver's license. 2) enclose a copy o proo o identity. 3) enclose the original extract ro the Chaber o Coerce (t older than 6 onths). 1

2 Other inoration how long has the driver had a valid driver's license? did the driver operate the otor vehicle at the instructions or with the perission o the insured? was the otor vehicle rented? was the driver involved in a otor vehicle accident during the past 5 years? i so, how oten? speciy the cause was the driver under the inluence o alcohol, edication, anaesthetics, stiulants and/or intoxicating or hallucigenic drugs while driving the otor vehicle? Daage to the vehicle(s) policyholder / driver ake/type registration nuber chassis. construction year color what was the extend o the daage/loss to the otor vehicle? other party ake/type registration nuber chassis. construction year color what was the extend o the daage/loss to the otor vehicle? when and at which garage is the otor vehicle being repaired? when and at which garage is the otor vehicle being repaired? insured with ENNIA insured with the ollowing copany based on the ollowing conditions Third Party Liited Coprehensive Extra Coprehensive Ideal Coprehensive based on the ollowing conditions Third Party Coprehensive other, naely Other party details aily nae aiden nae, i arried initial(s) street house. country irst nae phone gender ax cell city / country o birth e-ail nationality bank arried single living together bank account. driver s license. 5) job 2 occupation 5) enclose a copy o the driver s license. eployer

3 Sketch o the situation o the collision Speciy the ollowing properly: 1. road situation 2. driving direction o vehicles A and B 3. Position when the accident occurred 4. traic signs 5. street nae/roads indicate using an (arrow) the place where the vehicle was irst hit. driver A visible daage to the vehicle: other party B visible daage to the vehicle: rearks rearks who ade a record o the accident? the police TRS CRS BSF other, naely Forensys stap i applicable Declaration o the driver / policyholder / details 6) 3 6) please use the rear sheet to provide urther explanation.

4 Witnesses nae gender phone cell Accident when did the accident occur? tie city has the accident been reported to the copany by telephone? i so, when? i this is t the case, why t? speed? k/ph on which side o the road were you driving? on the let, center or right? who drove on the ain road? were the road conditions wet or dry? did you and the passenger(s) wear your/their helets or seat belts? as ar as you are aware, did the other party and the passenger(s) wear helets or saely belts? was a police report drawn up? (i, subit the police report at the request o your insurer) i this was t the case, why t? Victis nae phone / cell nature o injuries 7) relationship to the driver nae phone / cell nature o injuries 7) relationship to the driver nae phone / cell nature o injuries 7) relationship to the driver 7) please also coplete the injury or. 4

5 Explanatory te Declaration and signature As the policyholder I ust answer the questions in this or as copletely as possible. This also applies to acts and conditions that are related to other insured other than the policyholder. Questions o which you already assue the insurer has the answer ust also be answered as copletely as possible. The undersigned is aware that the insurance contract ay be terinated and/or the entitleent to a payent ay be liited or cancelled as a whole should this or contain incorrect or incoplete inoration. Be assured that ENNIA will be discrete with the (personal) data speciied on this or. city and country policyholder's signature driver's signature Explanatory te about personal data ENNIA will process the personal data that you subit or taking out and executing insurance contracts and other inancial services and to anage the relationships that arise ro this. The personal data will, oreover, be processed in relation to the support o activities that ocus on preventing and ighting raud and peroring activities that ocus on the expansion o services and increasing our relational database. Privacy regulations apply to the processing o personal data. The rights and duties o the parties with regard to data processing are deined in these privacy regulations. We will supply the privacy regulations ree o charge upon request. 5

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