NOTIFICATION OF CLAIMS

Please fill out your claim form

Third party liability damage (not caused by motor vehicle)

Responsible person

Surname(Required)

First-name(Required)

Company(Required)

Phone number(Required)

Email(Required)

IBAN or PC number

Subject to VAT

Yes

Claims data

Date of damage or when a problem was first detected(Required)

Location of damage/address(Required)

Date of damage or when a problem was first detected(Required)

Injured parties

1st party (name, address, possibly telephone/e-mail)

2nd party (name, address, possibly telephone/e-mail)

3rd party (name, address, possibly telephone/e-mail)

Damage to or destruction of third party property/Claims from third parties

Describe the extent of the damage/defect as far as possible

Type of damage

Estimated amount of damage in CHF

Existing claims in CHF

Description of damaged property or other claims

Age of the damaged item

Additional remarks

Cause of damage

Fault on your part or on the part of your employees

Remarks

Fault of a subcontractor

Remarks

Fault of the injured party

Remarks

Fault of third party/other business person

Remarks

Additional remarks

In the case of personal injury

Surname

First name

Nature of the injury

Name of the doctor

Notes on personal injury

Police report

Has a police report been made?

Yes

If yes: Police station, date of report and officer in charge

Miscellaneous

Remarks

Drop files here or

Max. file size: 5 MB, Max. files: 5.

(You can add up to five attachments here. You are welcome to submit any additional documents to schaden@verlingue.ch.)