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Damage report Online

Accident report: Information about the contract
Contract number

Registration number*

Information about the vehicle owner
Vehicle owner / company*

Name of the company car user (only long-term users), Dept*

Telephone*

Fax

Email*

Website

Timestamp

Information about the vehicle
Vehicle type*

Manufacturer*

Model*

Date registered (YYYY-MM-DD)*

Current mileage*

* Obligatory field
Information about the accident: Time and place of accident, driver information

When did the accident take place?
Day of the week*

Date (YYYY-MM-DD)*

Time*

Where did the accident take place? (exact description of place, including country code if abroad)*

Who was the driver at the time of the accident if not the company car user? (Name, address, age, telephone number, email)*

Did the accident occur on a business trip?*

Were you or the driver under the influence of alcohol / drugs at the time of the accident?*

If yes, was a blood sample taken?

Result of the blood test (in parts per thousand), if applicable

Were you / the driver in possession of a valid driving licence at the time of the accident?*

Information about the driving licence
Issued by

Issue date (YYYY-MM-DD)

Licence class

* Obligatory field
Information about the other party: Information about people involved

Who else was involved in the accident, apart from you / the driver?
Surname, name

Street, house number

Postcode, town

Telephone number

Registration number of other party

Insurance company

Insurance policy number of other party

What damage was visible on the other party's vehicle? (Please describe in as much detail as possible)

Was anybody hurt?*

If anyone was hurt: name and address of the injured party

* Obligatory field
Information about the damage: Damage to the company car
What damage was done to the company car?

Did the police record the damage?*

If yes, address of police station

File reference

If you know of anyone who witnessed the accident, please provide their name and address.

Description of the accident
How did the accident occur? Please describe, in particular, the road and weather conditions, speed of travel, road signs and braking distance.

File attachments for your accident report
Attachments
Please only use the following file types: *.pdf, *.jpg/jpeg, *.png.
Maximum file size: 15MB
Filename:

Final statement

I have answered all the questions truthfully and to the best of my knowledge. I am solely responsible for the accuracy of my statements. I am aware that deliberately making false or incomplete statements may result in the loss of insurance coverage.

I agree with the final statement*

Yes
Please insert the following data code in the box below. *

Ja, ich möchte eine Bestätigungsmail erhalten.
* Obligatory field

Service-Hotline

In all matters relating to accidental damage, repair approvals, vehicle returns or contractual matters.

Accidental damage: +49 6172-88-2460
Vehicle: +49 6172-88-2488
Contract: +49 6172-88-2499

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