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DEUTSCHE INVESTITIONSSCHUTZ VERSICHERUNG AG
INVESTMENT LOSS INSURANCE CLAIM FORM
Schadensmeldung für Investitionsverluste
Important:
Please complete all sections of this form and attach all required documentation. Required fields are marked with
*
. The form auto-saves your progress.
1. POLICY INFORMATION / VERSICHERUNGSANGABEN
Policy Number
*
Please enter your policy number
Policy Holder Name
*
Please enter the policy holder name
Policy Start Date
Policy End Date
2. CLAIMANT INFORMATION / ANTRAGSTELLER ANGABEN
First Name
*
Please enter your first name
Last Name
*
Please enter your last name
Address
*
Please enter your address
City
*
Please enter your city
Postal Code
*
Please enter a valid postal code
Country
*
Select Country
Deutschland
Austria
Switzerland
Other
Please select your country
Phone Number
*
Please enter your phone number
Email Address
*
Please enter a valid email address
3. INVESTMENT DETAILS / INVESTITIONSDETAILS
Business/Company Name
*
Please enter the business name
Type of Business/Investment
*
Startup/New Business
Technology Company
Manufacturing
Retail/Commerce
Real Estate
Financial Services
Other
Please select the type of business
Total Investment Amount (€)
*
Please enter the investment amount
Investment Date
*
Please enter the investment date
Investment Description
*
0
/2000 characters
Please provide investment description
4. LOSS DETAILS / SCHADENSDETAILS
Date Loss Became Apparent
*
Please enter when the loss became apparent
Claimed Amount (€)
*
Please enter the claimed amount
Cause of Loss
*
Business Failure
Fraud/Misrepresentation
Market Conditions
Management Failure
Regulatory Issues
Other
Please select the cause of loss
Detailed Description of Loss
*
0
/3000 characters
Please provide loss description
Recovery Attempts Made
0
/1500 characters
5. REIMBURSEMENT BANK ACCOUNT / BANKVERBINDUNG FÜR ERSTATTUNG
Account Holder Name
*
Please enter the account holder name
Bank Name
*
Please enter the bank name
BIC/SWIFT Code
*
Please enter a valid BIC/SWIFT code
IBAN
*
Please enter a valid IBAN
Bank Address
0
/300 characters
I confirm that I am the authorized account holder and that the provided bank details are correct.
*
6. SUPPORTING DOCUMENTATION / BELEGE
Please check all documents that you are submitting with this claim:
Bank Account Verification (e.g., bank statement or letter)
Investment Agreement/Contract
Bank Statements showing investment
Business Records/Financial Statements
Correspondence with business partners
Legal Documents (if applicable)
Other relevant documentation
Additional Documentation Description
0
/1000 characters
7. DECLARATION / ERKLÄRUNG
I declare that the information provided in this claim form is true and complete to the best of my knowledge.
*
I authorize the insurance company to investigate this claim and contact relevant parties.
*
I understand that providing false information may result in claim denial and potential legal action.
*
8. SIGNATURE / UNTERSCHRIFT
Claimant Signature / Unterschrift Antragsteller
*
Clear
Download
Please provide your signature
Date / Datum
*
Please enter the signature date