Online Claim Report | AtlanticTrust Insurance Brokers GmbH

Fill out this form in order to provide us with a detailed explanation of your case.
Please answer all questions carefully and truthfully!

Please note that all sections must be filled in! If you can not answer an action, please fill in "d.k.".

Policy Number

Personal Information

Name and address of policy holder

Phone number

Name and date of birth of driver of your vehicle

Driver's license number

Vehicle Information

Year, model, VIN#

License plate number

Is your vehicle damaged?

If yes, describe type and area of damage

Is your vehicle still driveable?

Where can your vehicle be inspected now?

Who did finance your vehicle? (lien holder information with address and phone number)

Accident Information

When did the accident happen?

Location / address

At what time did the accident happen?

Please give description of how the accident occurred

Has the accident been reported to the MP or German police (Polizei)?

If yes, please send us a copy of the MP/Polizei Report.

Were you or the driver of the vehicle driving under the influence of alcohol?

Were you or the driver driving under intoxication of drugs?

Claimant Information

Are there any witnesses to this accident?

Was there anybody else involved in the accident?

Did this person drive under intoxication of alcohol or drugs (DUI)?

yes
no
don't know

Did you hit anything else? (e.g. a guard rail)?

Are there any injured third parties?

If yes, who?

DUTY OF TRUTHFULNESS

Dear customer, please be advised that if you do not give us truthful information with deliberate intention or no information at all or do not make the respective bills and receipts available to us, you will lose your entitlement to your insurance benefit. If you violate these obligations in a grossly negligent manner you will in fact not lose your entitlement completely but we can cut our benefits in relation to the severity of your fault. The benefits will not be cut if you can prove that the obligation was not violated in a grossly negligent manner. If you violate the obligation for information or support or for the delivery of bills and receipts fraudulently, no actions shall lie against the insurance company.