Please send your documents toInsurance no.

HanseMerkur Reiseversicherung AGAbt. RLK
Postfach20352 Hamburg

Liability damage notice
Dear Policyholder
In order to process your case efficiently we require specific information from you. Please complete this form as
accurately as possible to avoid any unnecessary queries. Thank you for your cooperation and do not hesitate tocontact us if anything is unclear to you.
Data protection notice: we store your personal data for the purposes of assessing our service obligations.
For further information on data protection and your rights go to https://www.hmrv.de/en/privacy/information orplease request a copy from us.
General Information
Policyholder: Is the above address not correct, please tell us your new address
Tel.-No (during the day):Fax, Email:Name of Claiment (aggrieved party)
Last Name:First Name:
Street:
Zip-Code/City:
Tel.-No. (during the day):Street:When and where did the damage/accident occur?
Date:

Exact time:

Place:

Street:
RHV 001 DE GB 03.23 PDF A 003745 - 085 - 000290 - 000000000001

Page 1 of 6
HanseMerkur Reiseversicherung AG
Siegfried-Wedells-Platz 1, 20354 Hamburgwww.hmrv.deLiability damage notice

Insurance no.

Relationship to the claimant (aggrieved party):
Do any family ties or kindship bonds exist between:
you and the aggrieved party?

□ No □ If so, which?

Does any labor, employment or any other contractual
relationship exist between you and the aggrieved party? □ No □ If so, which?
Is he/she member of the house community?

□ No □ If so, which?

Information concerning the damage:
Exact description of the damage event and its circumstances with drawing (If space is insufficient, please use
separate sheet)

Drawing:

If have taken photos, please send them along.

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HanseMerkur Reiseversicherung AG
Siegfried-Wedells-Platz 1, 20354 Hamburgwww.hmrv.deLiability damage notice

Insurance no.

Notes to the police admission:
Was the damage recorded by the police?

□ No □ Yes

Address:
Tel-No.:File-No.:Has a fee-based warning been issue?

□ not known □ No □ Yes, against
Have criminal or fine proceedings been initiated?

□ not known □ No □ Yes, against
Witnesses (please note more witnesses on an extra sheet with name and address. Thank you!)
Name:
Address:
Zip-Code/City:
Involved as:
Tel-No.:Involved as:

Causation
On which grounds are you or any of your family members or any person placed under your custody blamed for
causing this damage?
Which person caused the damage/accident?
Date of birth:

Occupation:

May the aggrieved party be blamed his-/herself for causing the damage? To what extent?

□ No □ Yes, because
Have compensation claims been raised against you? (please attached documents)□ Not yet □ No □ Yes, at:through:

Do you approve of granting any pecuniary compensation directly to the claimant?

□ Yes □ If so, why
Do you make your own claims if necessary?

□ No □ Yes, against:

Have you hire a lawyer?

□ No □ Yes, name, address, Tel.-No.

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HanseMerkur Reiseversicherung AG
Siegfried-Wedells-Platz 1, 20354 Hamburgwww.hmrv.deLiability damage notice

Insurance no.

Please answer in case of material damage: including animals
What kind of property was damaged?
What is the nature of the damage?
When and at which price was the property acquired?

EUR□ No □ Yes □ Unknown

Do you think a restoration is possible?
To which amount may the damage be valued?

EUR□ No □ Yes

Does this valuation consider any depreciation of or prior damages to the property
Had the damaged property beenrented,

Was it consignment goods?

□ No □ Yes□ No □ Yes□ No □ Yes□ No □ Yes

Is the damaged property rented part of a structure/building?

□ No □ Yes

Did the damage to this property occur by an activity(e.g. processing, repairing, transporting it etc.)?

□ No □ Yes

borrowed,taken on lease or into safekeeping by you?

Where can the damaged property be inspected?
Name / Company:Tel.-No.:

Address:
Has the damaged property been insured?

□ Unknown □ No □ Yes, atAddress:

Policy No.:

□ Glass □ Fire □ Water □ Household or □ other Insurance:
Has the damage been reported there?

□ No □ Yes, atPage 4 of 6
HanseMerkur Reiseversicherung AG
Siegfried-Wedells-Platz 1, 20354 Hamburgwww.hmrv.deLiability damage notice

Insurance no.

Please answer in case of personal injury:
Name and address of the injured person:
Date of birth of the injured person:
What is the nature of the injury?
Which doctor treated the injured person?
Name, address and subject:
Was a hospital treated necessary?
from□ No □ Yes □ Unknown

to

Marital status of patient

Address of the hospital□ single □ married □ divorced □ widowed?

WHow many children has the patient got?

Aged?

What is the approximate income of the injured party or his/her spouse?

EUR / MonthIs the injured party entitled to third-party compensation (health insurance, employee’s industrial compensationsociety or similar bodies)? □ No □ Yes, atPlease do not staple or attach documents. Thank you for your help.
I expressly confirm that I have answered all questions and information truthfully and completely. I acknowledge
that incorrect and incomplete information provided consciously (deliberately) will result in the complete loss of
insurance cover, even if HanseMerkur Reiseversicherung AG does not suffer any disadvantages and yourinsurance cover is not endangered. Please also sign the declarations on the next page.

Place, Date

Signature of insured party (party causing damage)

Signature of policyholder

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HanseMerkur Reiseversicherung AG
Siegfried-Wedells-Platz 1, 20354 Hamburgwww.hmrv.deLiability damage notice

Insurance no.

Information on the consequences of breach of duty after the insured incident has occurredInformation under Sec. 28 para. 4 VVG
Dear customer
After the insured incident has occurred, we require your assistance.
Duty to provide information and assist in clarification
On the basis of the contractual agreement entered into, we may ask you to provide us with all information that is necessary toclarify the scope of liability (duty to provide information) and to clarify the matter fully (duty of clarification) to enable us tofully assess the claim. However, we may also request that you provide us with supporting documents, provided that such re­quests are reasonable.
Loss of benefits
If, contrary to the contractual agreements, you fail to provide us with information or give incorrect information, or wilfully failto provide us with the supporting documents that we request, you will lose your entitlement to compensation. If breach ofsuch obligations is based on gross negligence, we may reduce the benefits in proportion to the seriousness of the negligence.
There will be no reduction if you prove that you have not been grossly negligent in infringing the obligations.
Notwithstanding a breach of your obligation to either provide information, assist in clarification, or provide supporting docu­
ments, we are still obliged to pay compensation insofar as you can prove that any violation of duty was neither the result ofestablishing the scope of the insured incident or the scope of our liability.
If you fraudulently breach the obligation to provide information to clarify matters or to provide supporting documents, we willin every case be released from our liability to pay the claim.
Note:
If a third party, and not you yourself, is entitled to the benefits under the contract, such third party must also provide informa­tion assist in clarifying matters and provide supporting documents.

Place

Date

Signature of policyholder and insured or legal representative
Final statement
I confirm that the information I have provided above is true and complete. I am aware that incorrect or incomplete information
may lead to loss of insurance cover. I have taken note of the above information in accordance with Sec. 28 para. 4 of the Insu­
rance Contract Act (obligation after the insured incident).
In addition I assign my claims and demands against a third party causing the accident / liable party or against my statutory he­alth insurance fund / private health insurer to the amount of the compensation paid by HanseMerkur Reiseversicherung AGto HanseMerkur Reiseversicherung AG.

Place

Date

Signature of policyholder and insured or legal representative

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HanseMerkur Reiseversicherung AG
Siegfried-Wedells-Platz 1, 20354 Hamburgwww.hmrv.de