Please use this form only for registering claims without any connection with an insurance contract. For any claims concerning an insurance contract use the following form: File a claim for policyholders

    Salutation (optional)

    First name (optional)
    If forename and surname are not available separately (e.g. in the case of a company), the forename field must be left empty

    Surname (mandatory)
    Company name or family name, please without academic title

    Street (mandatory)

    PO Box (optional)

    ZIP Code (mandatory)

    Residence / Town (mandatory)

    Country (mandatory)

    Date of Birth (optional, e.g. 31-08-1971)

    Telephone number including countrycode (optional)

    E-Mail (optional)

    Bank account / Bank name (mandatory)

    BIC (mandatory)

    IBAN (mandatory)

    Claim (mandatory)
    Claim sum

    Currency (mandatory)

    Interest (optional)
    Interest claim sum. Please enter only digits

    Interest reason
    Type and reason for the interest claim / calculation from due date until 17.11.2016

    Other reason
    Nature and reason for the other benefit

    File upload (optional)
    Click here if you want to upload some files

    Please attach e.g. supporting document, calculation

    File 1 (max. 5 MegaByte):

    File 2 (max. 5 MegaByte):

    File 3 (max. 5 MegaByte):

    Comment (optional)