Please use this form only for registering claims from an insurance contract. For any other claim use the following form: File a claim for non policyholders

    Policy number (mandatory)
    If a client has concluded several insurance contracts (policies), then a separate dataset for each policy should be registered.

    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)

    Premium refund (optional)
    Sum of reclaimed premium; for calculation, please add attachment

    Claim (optional)
    Claim sum from insurance benefit

    Currency (mandatory)

    Claim status (optional)

    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 / please note: there is no interest on premium refund

    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. policy, calculation, any other supporting document

    File 1 (max. 5 MegaByte):

    File 2 (max. 5 MegaByte):

    File 3 (max. 5 MegaByte):

    Comment (optional)