Claims notification form - Liability insurance
Claims no. (for insurance company)
Policyholder: Phone office:
Street: Mobile phone:
Zip code / Postal code: Facsimile:
Contact person: Email:
Are you registered for VAT ?
Are you able to recover VAT from the Tax Authorities?
Do you have a legal protection insurance ?
If yes, which insurer ? Has the claim been reported ?
BANK DETAILS FOR CLAIMS PAYMENT
Name / Company: Bank and address:
Postal account: IBAN:
Description of the claim
Policy / authorities involved ?
Date and time: Who notified police ?
Ascertained on: Date of notification:
Location: Police station:
Street: Police officer:
Notification of public authority: Phone no.:
Cause of loss Drawing
Who caused the loss ?
Name, First name: Date of birth:
Is this person a relative of the policyholder ? Degree of relationship ?
Is this person employed by the policyholder ? Position:
Cause of loss ? What / who has caused the loss ?
Has the wrongful act been committed by a family member or an employee ?
Faulty / deficient material and/or installation ?
Any wrongful act committed by the claimant and or a third party ?
Name, First name, Address: Phone no.
Details / Data of injured or killed persons
Name, First name Address Date of birth Phone no.
Profession Employer Insurance Company ?
(SUVA, Accident insurer, health insurance)
Nature of injury Name+Address of the doctor / hospital
Damages or destruction of third party property / animals
Description of property damaged (by motor vehicle: model and licence plate) Age / Age-group Nature of the damage ?
Name, First name, Address of the owner Phone no.
Location of inspection / Repairing Company Estimated amount of loss Insurer ?(Hull Insurance / Fire/Water insurance etc.)
Is the claimant employed or appointed by you ? in which position/function:
Are you employed or appointed by the claimant ? in which position/function:
Has the incident occurred during work
whilst forming part of a joint-venture ? Name of the joint-venture:
Have claims for compensation
already been filed ? Amount claimed in CHF:
The undersigned authorizes the insurance company to obtain any information regarding the claim from other insureds or third parties and to examine any
official and court documents which are related to the claim. Furthermore, the insurance company has the right to remit data to official or legal institutions
and to any other insurance companies (co-insurers or reinsurers) in Switzerland and abroad which are involved in the claim. The undersigned is asked to
abstain from accepting any claims without prior contacting the insurance company.
Place and date Signature / stamp of the insured
Please send or fax the completed and signed claims notification form to:
Kessler & Co AG Contact person Kessler & Co: Phone direct:
Forchstrasse 95 / Postfach
Tel. 044 387 87 11
Fax 044 387 87 00
Kessler & Co AG Kessler & Co SA Kessler & Co SA Kessler & Co AG Kessler & Co AG Kessler & Co AG Kessler & Co AG
Forchstrasse 95 / 32, av. de Frontenex Rue Pépinet 1 Regionalbüro Regionalbüro KESSLER TMR AG Regionalbüro
Postfach 1211 Genève 6 1002 Lausanne Aarau/Solothurn Basel Zentrumsplatz 7 Innerschweiz
CH-8032 Zürich Tel. 022 707 45 00 Tel. 021 321 60 30 Rohrerstrasse 102 Freie Strasse 35 Postfach Weggisgasse 1
Tel. 044 387 87 11 Fax 022 707 45 01 Fax 021 321 60 49 5001 Aarau 4001 Basel 3322 Schönbühl 6000 Luzern 5
Fax 044 387 87 00 Tel. 062 825 05 05 Tel. 061 263 20 01 Tel. 031 858 30 30 Tel. 041 410 96 66
Fax 062 825 05 06 Fax 061 262 20 36 Fax 031 858 30 35 Fax 041 410 96 65