Claims report Engineering insurance

• 1When and where did the loss/damage occur?
• 2How did the damage occur?
• 3What damage occurred?
• 4How high do you estimate the damage?
• 5Was the damage reported to the police?
• 6If the damaged items are not at your address: Where can they be inspected?
• 7Would you like to attach documents?
• 8Are you the policyholder?
• 9What is the policy number?
• 10Policyholder
• 11What are your payment details?
• 12Would you like to notify us about something else?
• 13You have almost completed the form

When and where did the loss/damage occur?

Form UUID

Checksum

ThankYou-page URL

Form sub-type

Hidden controls

Client context

Agency ID

Interest ID

Date

Place

Street

Country

Which country

How did the damage occur?

Please describe the course of events

What damage occurred?

Please list all damage

How high do you estimate the damage?

Select amount

Was the damage reported to the police?

Yes

No

Who submitted the notification?

Which police office filled out the report?

Name of the officer

If the damaged items are not at your address: Where can they be inspected?

Place

Street

Repair company

Contact person

Phone number of contact person

Would you like to attach documents?

Select a file

Are you the policyholder?

Yes

No

You are

Title

Mr.

Ms.

First name

Last name

Phone number

Email address

Re-enter the email address

First name

Last name

Company

What is the policy number?

Policy number

You can find the policy number on an AXA contract or invoice (e.g. xx.xxx.xxx).

Policyholder

Title

Mr.

Ms.

Company

First name

Last name

Street

House number

PO Box

Postcode

Place

Country

Which country

Phone number

Email address

Re-enter the email address

Company

Street

House number

PO Box

Postcode

Place

Country

Which country

Contact person

Title

Mr.

Ms.

First name

Last name

Phone number

Email address

Re-enter the email address

What are your payment details?

Payment types

Bank account

Postal account

ESR (payment slip with reference number)

Are you the policyholder?

Yes

No

Account in the name of

Please enter the precise account descriptions. In the case of a joint account, please enter both names.

Postcode

Place

IBAN

Please note:
You can find your IBAN on account statements, notifications, and debit cards (Maestro cards and account cards). Or determine your IBAN number here.

BIC

Here you can determine the BIC number.

Account number

Reference number

Financial institution

Postcode

Place

Please note: You can attach all open ESR invoices at the end of the claims notice.

Would you like to notify us about something else?

Your message

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