[non-prod] Claims Notification Form / First Notice of Loss FINAL (incl. Event Country)

Claims Notification Form / First Notice of Loss
DE Formular in deutscher Sprache verfügbar (siehe oben rechts)
FR Formulaire disponible en Français (voir en haut à droite)
IT Modulo disponibile in Italiano (vedi in alto a destra)
Information Related to the Loss

The fields marked with * are mandatory, however we kindly ask you to fill in as many fields as possible.
Loss date*

DayMonthYear
Loss location*

Street Address or Road Number

Street Address Line 2 (optional)

CityState

Postal / Zip Code
Country of event
Country of the insurer of the party responsible for the loss
Name of the insurer of the party responsible for the loss*
Please type in the name of the insurer
Country and insurer of the party responsible for the loss
License plate number of the vehicle responsible for the loss*
Example: EW123452
Country of registration of the vehicle responsible for the loss*

Contact details of the damaged party

The fields marked with * are mandatory, however we kindly ask you to fill in as many fields as possible.
The damaged party is a*

personcompany
Name of the company*
Name of the damaged party*

SalutationFirst NameLast Name
Address of the damaged party*

Street Name

Street Number

CityState / Province

Postal / Zip CodeCountry
Email address of the damaged party*
example@example.com
Mobile phone of the damaged party

Country CodeArea CodePhone Number
Landline of the damaged party

Country CodeArea CodePhone Number
IBAN
BIC
Bank
Account holder

Type of loss

The fields marked with * are mandatory, however we kindly ask you to fill in as many fields as possible.
Type of damage*

Material vehicle damageBodily injuryAny other material damage
Please provide a short accident description:

0/1000

If the loss includes a damage to a vehicle

The fields marked with * are mandatory, however we kindly ask you to fill in as many fields as possible.
Licence plate number*
Example: EW12345
Year of manufacture*
Mileage on the day of the loss
In kilometre
Vehicle make*
Model*
Name of your insurance company*
Insurance number
Do you have a fully comprehensive insurance package ?*

YesNo
Is your vehicle leased/financed (private) ?*

YesNo
Is your vehicle a business asset (e.g. company car) ?*

YesNo
Is there an entitlement to deduct an input tax ?*

YesNo
If the driver and the damaged party are different people, please fill in the driver's contact details below:

SalutationFirst NameLast Name
Phone Number of the driver

Country CodeArea CodePhone Number
Address of the driver

Street Name

Street Number

CityState / Province

Postal / Zip CodeCountry
Email of the driver
example@example.com

If the loss includes an injury to a person

The fields marked with * are mandatory, however we kindly ask you to fill in as many fields as possible.
Name of the injured person

SalutationFirst NameLast Name
Address of the injured person

Street Name

Street Number

CityState / Province

Postal / Zip CodeCountry
Email of the injured person
example@example.com
Phone number of the injured person

Country CodeArea CodePhone Number
Occupation
Name of the company
Employer's address
Nature and extent of the injury(ies)
Has the injured person been hospitalised?

YesNo
If yes, between what dates:
Name and address of the hospital
Name and address of the doctor in charge of the injured person
Add other attending physician
Is the injured person unable to work ?

YesNo
If yes, between what dates:
Name and address of the health insurance company of the injured person
Is this a work accident ?

YesNo
Did the accident occur on the way to or from work ?

YesNo
Name and address of the employer's liability insurance
Please upload your waiver of confidentiality below

Cancelof
Add another injured person

If the loss includes a damage to another type of property

The fields marked with * are mandatory, however we kindly ask you to fill in as many fields as possible.
What type of property and what is the damage ? (Please provide at the end of this form photos of the damage, proof of purchase and/or proof of value)

0/100
Please summarise the events that led to the damage of your property. Where were the damaged items located at the time of the accident ?

0/1000

Details of the owner of the vehicle responsible for the loss

The fields marked with * are mandatory, however we kindly ask you to fill in as many fields as possible.
The vehicle is owned by*

a persona company
Name of the company owning the vehicle responsible for the loss*
Name of the owner of the vehicle responsible for the loss*

SalutationFirst NameLast Name
Address of the owner of the vehicle responsible for the loss

Street Name

Street Number

CityState / Province

Postal / Zip CodeCountry
Email of the owner of the vehicle responsible for the loss
example@example.com
Mobile phone of the owner of the vehicle responsible for the loss

Country CodeArea CodePhone Number
Landline of the owner of the vehicle responsible for the loss

Country CodeArea CodePhone Number

Details of the vehicle responsible for the loss

The fields marked with * are mandatory, however we kindly ask you to fill in as many fields as possible.
License plate number*
Year of manufacture
Vehicle make *
Model
Name of the insurance company*
Insurance number
If the driver responsible for the loss and the owner of the vehicle responsible for the loss are different people, please fill in the driver's contact details below:

SalutationFirst NameLast Name
Phone Number of the driver

Country CodeArea CodePhone Number
Address of the driver

Street Name

Street Number

CityState / Province

Postal / Zip CodeCountry
Email of the driver
example@example.com

Other people involved in the loss or who witnessed it

The fields marked with * are mandatory, however we kindly ask you to fill in as many fields as possible.
Police involvement:

No police presenceNot present, accident reportedPresent after accidentPresent, no report drawn upPresent, report drawn up
Police report file number
Name and address of the police station

0/50

Please upload below all the documents relevant to your claim

PLEASE MAKE SURE THAT EVERY FILE IS NAMED CLEARLY. This will ensure a faster processing of your claim.
Proof of involvement (e.g., photos of license plate, copies of ID card, copies of driver's license, witness data, etc.).

Cancelof
Proof of liability (police report or European accident report)

Cancelof
Estimated cost of damage (e.g., cost estimate, appraisal, repair bill, etc.).

Cancelof
Damage photos

Cancelof
Other documents that might be relevant

Cancelof
Which email address should we use for the dispatch confirmation?
example@example.com
If you have any interrogation and need to contact us regarding aspects of this form...

You can contact us by phone: +49 (0)221 95 42 06 0 (Monday-Friday 08:30-17:00) or by e-mail: schadenbuero@vanameyde.de
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Claims Notification Form / First Notice of Loss