A + A Assureurs Associés SA

Etude, placement et gérance de portefeuilles d’assurances

Place St-Gervais 1 I CP 1213 I CH-1211 Genève 1

t +41 22 716 19 19 I f +41 22 731 85 21

info@synerisk.ch I www.synerisk.ch

Membre de

Insurance Claim	Wealth Insurance

Insurance data

Contract Number
Claim file no. (for the insurer)

Policy Holder Information

Last name, first name or company
Street, postal code, city/town
Contact person
Work Phone	Fax
Email	Mobile

Bank data

Bank & location
Bank account number
IBAN or CCP
BIC

Other

Are you subject to VAT?	Can you reclaim VAT?
Yes No	Yes No

Do you have legal protection insurance?	Yes No
With which company?
Did you report the case?	Yes No

Circumstances of the incident

Date and time	Complaint filed on
Recorded on	Date of complaint
Street	Police station
Location	Police officer
Floor	Phone number
Police Report	Yes No
Description of the occurrence	Sketch

Perpetrator

Last name, first name, or company	Address
Date of birth	City/Town
Profession	Country

Is this person related to the policyholder?

Yes	No

If Yes, what is the nature of their relationship?

Is this person employed by the policyholder?

Oui	Non

If Yes, in what capacity?

Cause of the incident

A fault on your part, a member of your family or an employee	Yes No
Motive

Fault or concomitant fault of the injured party or a third party	Yes No
Motive
Last name/First name and address

Witnesses

Last name, First name and Address	Phone number

Bodily injury or death

Last name, first name
Date of birth
Address
Profession
Employer
Insured with which company (Suva, LAAO, health insurance)
Description of injuries
Name and address of doctor or hospital

Damage or destruction of things or animals belonging to a third party

What things were damaged? (for vehicles, indicate the brand and license plate numbers)	Age/Year	Description of damage

Owner(s) last name, first name, and address	Phone number
Location of damaged object/ Repair workshop	Approximate cost of damage (CHF)	Item insured with which company? (Ass. Casco, fire, water damage, etc…)

Additional questions

Is the injured party your employee?

Yes	No

If Yes, in what capacity?

Are you employed by the injured party?

Yes	No

If Yes, in what capacity?

Did the loss occur while working in a consortium of contractors?

Yes	No

If Yes, what is the consortium called?

Has the injured party already made claims?

Yes	No

If Yes, what is the claim amount? (CHF)

Additional Comments

Authorization

The undersigned authorizes the insurance company to request all information concerning the claim from the insured or third parties and to consult the official and legal documents relating to the claim. The insurance company is also authorized to transmit data relating to the claim to official or judicial institutions and to other insurance companies (co-insurer or reinsurer) in Switzerland and abroad. The undersigned is requested to refrain from accepting any claim of liability before contacting the insurance company.

All correspondence will pass through the insurance broker for supervision and support as needed.

Important Reminders

Article 3 of the Federal Law on Insurance Contracts (LCA) provides that the policyholder must do everything possible to limit the damage and notify the insurance company of the loss immediately.

Article 46 of the Federal Law on Insurance Contracts (LCA) provides that the claims arising from the insurance contract are time-barred two years from the date of the occurrence of the obligation for contracts taken out before 31.12.2021 and five years from the date of the occurrence of the obligation for contracts taken out from 01.01.2022. You must comply with the time limit.

Date and location:	Policy holder’s signature and stamp

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