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	Property and Liability 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 claim 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

Is anyone responsible for the damage?

Yes	No

If Yes :	Who
Name and address of witnesses

Is there any other insurance covering this claim?

Yes	No

If Yes :	Company
Contract number

Questions about fire insurance (fire, smoke, lightning, natural damage) and water damage

Did firefighters intervene?

Yes	No

What immediate damage mitigation and/or salvage measures were taken?

Where can objects be examined?

Questions about theft or loss insurance

What type of robbery was it?

Petty larceny	Burglary	Robbery

If burglary, how did the thief enter the premises?

Was there a loss?

Yes	No

Were the stolen or lost items kept under lock and key?

Yes	No

If Yes, please describe the contents:

Additional comments

List of damaged items Content (goods, technical installations, movable property, personal effects, etc.) Attention: for valuable insured items, please use the other form below

If the object is irreparable or was stolen, please attach the following: receipt, certificate of value, photograph(s), etc. for each of the objects mentioned below. If the object is repairable, please attach a repair estimate for each of the objects mentioned below.

Object belonging to the insured

Quantity	Object (brand, model)	Date of purchase	Purchase price (CHF)	Purchase location	Amount of claim (CHF)

Objects belonging to a third party*

*	Objects entrusted to the insured under trade insurance.

Quantity	Object (brand, model)	Date of purchase	Purchase price (CHF)	Purchase location	Amount of claim (CHF)

Owner(s) of damaged items

Last name, first name / company
Street, postal code, location
Phone number, mobile, fax, email

Last name, first name / company
Street, postal code, location
Phone number, mobile, fax, email

List of damaged items Valuable objects

If the object is irreparable, stolen or lost and if the sum insured is agreed upon in declared value, please enclose the following: receipt, certificate of value, photograph(s), etc. for each of the objects mentioned below. If the object is repairable, please attach a repair estimate for each of the objects mentioned below.

Position in the insurance policy	Object (brand, model)	Date of purchase	Purchase price (CHF)	Amount of claim (CHF)
List of damaged items Building damage

Please enclose all the repair estimates for the locations mentioned below.

Floor	Room	Nature of damage, repairs needed	Cost of damage (CHF)

Repair company?

Last name, first name / company
Street, postal code, location
Phone number, mobile, fax, email

List of damaged items

Broken glass

Please enclose all the repair estimates for the locations/objects mentioned below.

Quantity	Type of glazing/glass	Destination/ use of glass	Height (cm)	Width (cm)	Cost of damage (CHF)

Repair company?

Last name, first name / company
Street, postal code, city/town
Phone number, mobile, fax, email

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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