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If

Notification of a threat of an insurance loss

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NOTIFICATION OF A THREAT OF AN INSURANCE LOSS
GIC type If
Insurance Contract number:
Insurance Decision number (for framework contracts):
Cause of an insurance loss according to GIC I f Art.. X.:
Supplementary insurance of exchange rate risk (for contracts before December 31, 2006):
    
I. Insured
Commercial name:
Company Identification No.:
Seat:
Phone:
Fax:
E-mail:
Contact Person:
Bank Connection:
Authorised Person:
II. Debtor
Commercial name:
Seat:
State:
Debtor:     
Phone:
Fax:
E-mail:
Contact Person:
Bank Connection:
III. Investor
Commercial name:
Company Identification No.:
Seat:
State:
Phone:
Fax:
E-mail:
Contact Person:
Bank Connection:
IV. Commentary and data on incurred loss:
Commentary Amount
Characteristics of business transaction:
Reasons and circumstances leading to a threat of an insurance loss (must be filled-in):
Following steps have been made in order to prevent an insurance loss (must be filled-in):
V. Instruction
  • the form has to be duly filled-in and signed by a person authorized to act outwardly on behalf of the company
  • the insured will continue in all necessary measures in cooperation with the insurer to prevent origination of an insurance loss or to lower its extent
  • the insurer has the right to take all necessary measures in cooperation with the insured or independently leading to prevention of an insurance loss or to lowering of its extent
VI. Attachments
  • Documentation on extent of material damage and on circumstances causing it
  • Correspondence related to insured investment
  • Contract on credit for investment
  • Other attachments:
Number of attachments:
Date:
Signature of insured: .....................................................................................
 
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