Additional information regarding the accident report (general questionnaire)

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Claim No. (see cover letter)

Please provide your claim number.

Identification code (see cover letter)

Please provide your identification code.

Please select a salutation.

Name

Please provide your last name.

First name

Please provide your first name.

Date of birth

Please provide your date of birth.

Please provide your email address.

Additional details about the accident report

Date of the accident

Please provide the date of the accident.

Time of the accident

Please provide the time of the accident.

Where did the accident happen?

Please provide the accident location.

How did the accident happen?

Please describe the course of the accident.

Was this a habitual activity?

Please answer the question completely.

When did the symptoms first appear?

Please answer the question completely.

Were other people involved?

Please select.

Please provide the name, exact address and, if known, liability insurance incl. policy number and insurance agency.

Please answer the question completely.

Are there any witnesses?

Please select.

Please provide the name and exact address.

Please answer the question completely.

If you were unable to work – are you still unable to work?

Yes
No
There was no incapacity for work

Please select.

Has the work been partially resumed?

Please select.

To what extent have you resumed your activity (in %)?

Input field for percentage.

When did you return to work?

Please answer the question completely.

Has the treatment already been completed?

Please select.

Were you already being treated for similar symptoms prior to the aforementioned incident?

Please select.

Please provide the name and address of the doctor treating you at the time.

Please answer the question completely.

Who covered the costs at the time?

Bitte beantworten Sie die Frage vollständig.

Please also state the name, exact address and policy number of your health insurance company.

Please answer the question completely.

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