Claim form for a motor vehicle/motorcycle accident
1
To be completed by ENNIA advisor policy no. agent name agent no. claim no. phone agent customer no. name advisor advisor no. phone advisor Policyholder private individual street family name
maiden name, if married
date of birth city / country of birth
nationality country phone m f house no. area initial(s) first name gender
driver’s license no.1) occupation
employer job
cell fax
bank
bank account no. e-mail living together married single street house no. area country family name initial(s) first name
driver’s license no.4)
Driver's details (if not the same as the policyholder's)
legal entity / business / company
name address area
primary place of business
sector of industry contact person2) job phone fax e-mail website
Name(s) of the person(s) who are stakeholders in relation to this company
1,4)enclose a copy of the driver's license. 2)enclose a copy of proof of identity. 3)enclose the original extract from the Chamber of Commerce (not older than 6 months).
d d m m y y y y
Trade reg. no.
Chamber of Commerce3)
date of birth
Damage to the vehicle(s) policyholder / driver make/type make/type registration number chassis no. registration number chassis no.
construction year construction year
color color
what was the extend of the damage/loss to the motor vehicle? what was the extend of the damage/loss to the motor vehicle?
other party
when and at which garage is the motor vehicle being repaired?
insured with ENNIA insured with the following company based on the following conditions
date
when and at which garage is the motor vehicle being repaired? date
other, namely
based on the following conditions
Other party details
street family name
maiden name, if married
city / country of birth nationality country phone m f house no. area initial(s) first name gender
driver’s license no.5)
cell fax
bank
bank account no. e-mail
yes no
yes no was the driver involved in a motor vehicle accident during the past 5 years?
if so, how often? specify the cause
was the driver under the influence of alcohol, medication, anaesthetics, stimulants and/or intoxicating or hallucinogenic drugs while driving the motor vehicle?
5)enclose a copy of the driver’s license.
did the driver operate the motor vehicle at the instructions or with the permission of the insured? yes no how long has the driver had a valid driver's license?
was the motor vehicle rented? yes no
Other information job employer occupation d d m m y y y y d d m m y y y y d d m m y y y y date of birth living together married single Third Party Extra Comprehensive Limited Comprehensive Ideal Comprehensive
Third Party Comprehensive
Sketch of the situation of the collision
Specify the following properly: 1. road situation • 2. driving direction of vehicles A and B • 3. Position when the accident occurred 4. traffic signs • 5. street name/roads
driver A
indicate using an (arrow) the place where the vehicle was first hit.
visible damage to the vehicle:
remarks
who made a record of the accident?
other party B
visible damage to the vehicle:
remarks
Forensys stamp if applicable
Declaration of the driver / policyholder / details6) the police TRS CRS BSF
other, namely
6)please use the rear sheet to provide further explanation.
Witnesses
name address gender phone cell
Accident Victims phone / cell m f name address
relationship to the driver
7)please also complete the injury form.
m f m f yes no yes no yes no speed?
was a police report drawn up? (if yes, submit the police report at the request of your insurer) if this was not the case, why not?
km/ph
on which side of the road were you driving? on the left, center or right? who drove on the main road?
were the road conditions wet or dry?
did you and the passenger(s) wear your/their helmets or seat belts?
as far as you are aware, did the other party and the passenger(s) wear helmets or safely belts?
yes no when did the accident occur?
time city
if this is not the case, why not? if so, when?
has the accident been reported to the company by telephone?
date d d m m y y y y name address nature of injuries7) nature of injuries7) nature of injuries7) name address d d m m y y y y date of birth phone / cell
relationship to the driver
d d m m y y y y
date of birth
phone / cell
relationship to the driver
d d m m y y y y
date of birth
5
Declaration and signature Explanatory note
As the policyholder I must answer the questions in this form as completely as possible.
This also applies to facts and conditions that are related to other insured other than the policyholder.
Questions of which you already assume the insurer has the answer must also be answered as completely as possible. The undersigned is aware that the insurance contract may be terminated and/or the entitlement to a payment may be limited or cancelled as a whole should this form contain incorrect or incomplete information.
Be assured that ENNIA will be discrete with the (personal) data specified on this form.
Explanatory note about personal data
ENNIA will process the personal data that you submit for taking out and executing insurance contracts and other financial services and to manage the relationships that arise from this.
The personal data will, moreover, be processed in relation to the support of activities that focus on preventing and fighting fraud and performing activities that focus on the expansion of services and increasing our relational database.
Privacy regulations apply to the processing of personal data.
The rights and duties of the parties with regard to data processing are defined in these privacy regulations. We will supply the privacy regulations free of charge upon request.
policyholder's signature driver's signature
date city and country
6
200.81.1.0313
