Household Contents Claim Form

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Below is the information as we have it on file. Would you like to review it and make any necessary changes?

Claim Number(Required)

Type of insurance(Required)

Policy Number(Required)

Name(Required)

First Name Insert Surname

Enter your ZIP code and house number

Phone number(Required)

Email address(Required)

Bank account number(Required)

I have reviewed the information above and made any necessary corrections.(Required)

Yes

No

General

What is the date of the claim?(Required)

Are you eligible for a VAT deduction?(Required)

Yes

No

Do you have coverage for the damage under another insurance policy?(Required)

Yes

No

Which insurance company?

Under which policy number?

What's damaged?

How many items were damaged?(Required)

1 item

2 objects

3 items

more than 3 items

Description of Damaged Item(Required)

Date of purchase (if known)

Purchase price (if known)

Description of Damaged Item(Required)

Date of purchase (if known)

Purchase price (if known)

Description of Damaged Item(Required)

Date of purchase (if known)

Purchase price (if known)

Please list the damaged items here. Brand/model. The purchase price, date of purchase, and any repair costs.(Required)

Do you have the purchase receipts? (If so, please attach them at the end of the questionnaire.)(Required)

Yes

No

Do you have any other information, such as receipts, debit card transactions, warranty certificates, and the like? If so, you can add them at the end of the form.

Yes

No

Damage

What is the nature of the damage?(Required)

Is the damage repairable? If not, please provide a statement from a repair technician confirming that repair is not possible.(Required)

Yes

No

Which company will repair the damage? (Name)(Required)

Which company will repair the damage? (Address)(Required)

Street + house number Location Postal code

Phone number

Email address

For what amount?

Do you believe someone else is responsible for the damage?(Required)

Yes

No

Why do you hold someone else responsible for the damage?

Would you like to provide the following information about the person in charge? (Name)

First Name Insert Surname

Would you like to provide the following information about the person in charge? (Address)

Street + house number Location State / Province / Region Postal code Country

Would you like to provide the following information about the person in charge? (Phone number)

Would you like to provide the following information about the person in charge? (Email address)

Closing

Space for questions and/or comments

If available, please provide us with the following documents: Photos of the damage; purchase receipt, contract, proof of delivery, or other proof of payment; the repair estimate or, if applicable, a statement confirming that repair is not possible; and, in the event of theft, a copy of your police report.

Drag files here or

Maximum file size: 2 MB.

The information provided may be processed in the Central Claims Information System. The privacy policy of the CIS Foundation applies to this registration.

The undersigned declares:

to have answered the above questions and completed the above assignments to the best of my knowledge, accurately and truthfully, and not to have withheld any details regarding this damage;
submit this claim form, along with any additional information that may be required, to the insurance company so that the extent of the damage and the entitlement to compensation can be determined;
to have read and understood the contents of this form.

Signature(Required)

CAPTCHA

Household Contents Claim Form

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General

Claim Data

What's damaged?

Damage

Closing

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