Iberia Insurance Admins & Associates


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Contact in Spain:

+34 971 69 90 96

Please study carefully the conditions of your insurance contract and answer all questions to the best of your knowledge. Incorrect or incomplete answers may invalidate your insurance coverage. All the fields marked with an asterisk (*) have to be completed!

Insured:* (VN):
Place of Loss:
Time of loss:
Loss first noticed:
First notification of insurer: (When and to whom?)

Policy Number:*
Telephon-No:*
Address:

Do Third Parties hold rights to the claimed objects?	Yes No
If yes, please enter details:

Are you entitled to set off Value Added Taxes? Yes No

Did – in your opinion - the loss result in Third Parties having any rights to claim compensation? (e.g. Third Party Liability, poor worksmanship, etc)	Yes No
If yes, please give details:

Is the claimed object also insured elsewhere?	Yes No
If yes, please give details:

Loss Amount
Precise amount of loss (EUR):
Estimated to be at most (EUR):
If the loss amount will later deviate significantly from this estimate please inform us without delay.

Prior losses

Have you or others of those who maynow suffer damages had previously losses?

Yes No

If yes, please state details (Object, date of loss, nature of loss and size of loss. Was the loss insured? If yes, please state name and address of the insurer)

Please give details concerning the incident / loss event

What happened? How and what was stolen / damaged? When and how could the incident occur? Please be as specific as possible.

Kindly also forward to us all documentation supporting the claim (photos, invoices and if available professional assessments.

Mitigation

What was done to reduce losses?

Loss payment

If a payment should be authoritzed to which account shall the transfer be made:

Account Holder:
Bank:
Account Number:

Obligations on behalf of the claimant / insured
I have been informed that I am obliged to answer all questions with respect to this loss to the best of my knowledge and to volunteer any information that may be of interest to the insurer. I take full resposibility for these answers even if the questionairre was filled in by another person. I am aware that incomplete or incorrect answers may invalidate the insurance coverage.

Email:

Name: