Material Damage Claim Form

First Name
Last Name *
Email address *
Phone number *
Date of Birth *
Home address *
Patient's phone number
Name of Contact Person
What do you want to report? *
Damage Missing/lost item
What is damaged or missing/lost? (please keep damaged items and show them on request) *
Has the damage/loss been reported to your (liability) insurer? *
Yes
No
Did or will the insurer pay (part of) the damage/loss?
No
Yes
When did you purchase the item? *
Do you have a purchase receipt?
Yes
No
In case of damage, do you have a recovery/repair receipt?
Yes
No
What was the purchase price/value? *
When were you admitted to the hospital? *
Date of damage/loss: *
In which department at the hospital did the damage/loss occur *
How did the damage / loss occur? *
In case of loss, was there a possibility to place your belongings in safekeeping?
Yes
No
If you answered the previous question with Yes, why were your belongings not placed in safekeeping?
Do you consider the hospital staff or a fellow patient responsible for the damage/loss?
Yes
No
If yes, please provide your reason
Are there witnesses of the incident?
Has the damage/loss been reported to the supervisor, management or an employee?
Has a report been filed with the police?
What (other) actions did you take to find the lost item or to repair the damaged item?
Do you give consent to SMMC to access your data ONLY for the purpose of handling this claim?
Yes
No
Today's Date