Loss report

General Technical Installations and Engineering Insurance

1Insured person

Policyholder
Person to contact / [CLICK!and add text]
Street
Postcode / Place
Telephone no. / VAT registered / ☐yes / ☐no
Bank account / [CLICK!and add text]
Bank / Branch / [CLICK!and add text]
Insurance carrier
Policy number

2Insured event

☐IT insurance / ☐Erection insurance
☐General technical installations insurance / ☐Construction insurance
☐Machinery breakdown insurance / ☐Other classes of insurance
(e.g. epidemic, additional costs insurance etc.)

3Loss occurrence

Date: / [Add Date]
Time: / [Add Time]
Street / Place / [Add Street/Place!]
Was any official report made of the facts? / ☐yes / ☐no
If so, by whom?
[CLICK!and add text]
Circumstances of the loss
[CLICK!and add text]
Please continue on a separate sheet if necessary
Where can the damaged property be inspected?
[CLICK!and add text]
Loss / damage occurred whilst:
☐in transit / ☐being erected / ☐being dismantled / ☐being tested
☐in operation / ☐shut down / ☐being repaired / ☐being over hauled
☐under construction / ☐being commissioned / ☐being load tested

4Witnesses

Last name, first name / [CLICK!and add text]
Telephone no. / [CLICK!and add text]
Addresses / [CLICK!and add text]

5Details of the loss

Name an address of anyone who may have caused the loss:
[CLICK!and add text]
Who was responsible for supervising the insured property at the time of the loss occurrence?
[CLICK!and add text]
Cause of loss / ☐operation / handling / monitoring error
☐construction / material / manufacturing error
☐external forces (e.g. natural hazards), namely: 
[CLICK!and add text]
Anticipated amount of loss / CHF[CLICK!and add text]

6Additional information for machinery breakdown / machinery own damage / it / general technical installations

Object (machine / plant / facility) affected by damage
[CLICK!and add text]
Date of purchase / [CLICK!and add text]
Purchase price / [CLICK!and add text]
Condition when purchased / ☐new / ☐used
Price today ( cost of replacement) / [CLICK!and add text]
Supplier / [CLICK!and add text]
Guaranty expired? / ☐yes, on / [CLICK!and add text] / ☐no
Service contract / ☐yes, with: / [CLICK!and add text] / ☐no
Hired out / ☐yes, to / [CLICK!and add text] / ☐no
Previous losses / [CLICK!and add text]
Last overhaul on / by whom? / [CLICK!and add text]
Has the loss resulted in an insured interruption of the business?
☐ / no
☐ / yes / (If so, expected duration?)
[CLICK!and add text]

7Additional information for erection and construction insurance

Commencement of erection/construction: / [CLICK!and add text] / Erection/construction amount: / [CLICK!and add text]
Location of erection/construction: / [CLICK!and add text] / Client: / [CLICK!and add text]
Management of erection/construction: / [CLICK!and add text]

8Is the above property covered by any other insurances?

☐Fire / ☐Theft
☐Glass breakage / ☐Water damage
☐Machinery breakdown / ☐Construction
Company? / [CLICK!and add text]

9Comments

[CLICK!and add text]
[CLICK!and add text]
[CLICK!and add text]
[CLICK!and add text]
[CLICK!and add text]
, 13 April 2019
client
[KLICK!client name eingeben]

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