Déclaration de sinistre dégâts d'eaux (PDF, 226 KB)

DECLARATION DE SINISTREDégâts d’eauxPreneur d’assuranceAdresse:……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………...……………………………………………………………………………...………………………………………………………………………………………………………………………………………………………………Numéro de police:……………………………………...Date du sinistre:……………………………………...Numéro de téléphone:……………………………………...E-Mail:……………………………………...Personne de contact:……………………………………...Relation bancaireNom / Adresse de la banque: ………………………………………………………………………………………….Titulaire du compte: ...........................…………………………………………………………………………….Clearing no: ............................................………………………………………………………………………….Compte no: ..……………………………………………………………………………………….…………………IBAN no: ......…...……………………………………………………………………………………………………..SinistreLieu (indication exacte):………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Circonstances du sinistre:…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………HDI-Gerling Industrie Versicherung AGDufourstrasse 46, Postfach 5218034 ZürichTel: +41 44 265 47 47Fax: +41 44 265 47 48

DECLARATION DE SINISTREDégâts d’eauxOù peut-on examiner les objets sinistrés?…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Quelle mesures de sauvetage ont été déjà prises?…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Quelqu’un est-il responsable de ce sinistre? Qui?…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………a) Inventaire du dommage, Objets mobiliers (meubles, marchandises etc.);Prière de joindre les justificatifs d’achat et autresQuantité: Objet (marque, type): *a/b/c Date d’achtat: Prix d’achat: Acheté où: Montant du dommage:……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Propriétaires des choses endommagées (réserve de propriété, etc.)…………………………………………………………………………………………………………………………...Existe-t-il d’autres assurances couvrant ce sinistre? (Transport, bris de machines, TRI, Ski, Objets devaleurs, assurance casco, etc.)Oui Non Compagnies:…..............................................................................................................* a = endommagé; b = détruit; c = voléHDI-Gerling Industrie Versicherung AGDufourstrasse 46, Postfach 5218034 ZürichTel: +41 44 265 47 47Fax: +41 44 265 47 48

DECLARATION DE SINISTREDégâts d’eauxb) Dommages aux Bâtiments:Etage: Local: Nature au dommage; réparations nécessaires: coûts approx..:……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………Propriétaire du bâtiment:…………………………………………………………………………………………………………………………...…………………………………………………………………………………………………………………………...Le soussigné autorise HDI-Gerling à consulter les documents officiels.Lieu et date:Signature:………………………………………………………………………………………………..HDI-Gerling Industrie Versicherung AGDufourstrasse 46, Postfach 5218034 ZürichTel: +41 44 265 47 47Fax: +41 44 265 47 48