Claims notification form Liability insurance (DOC) by xuyuzhu


									Claims notification form - Liability insurance

                                                                       Policy no.
                                                                       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 ?


Name / Company:                                                                  Bank and address:
Postal account:                                                                                IBAN:
                                                                                         Account no.:

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:
Address:                                                                                  Profession:
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:

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.)

Additional questions
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:

Additional comments

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
8032 Zürich
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

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