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