Motor Vehicle Accident Report Form Page 2
ADVERTISEMENT
1
24. ACCIDENT contd.
If “Yes” give details _______________________________________________
Insured Vehicle
Third Party Vehicle
__________________________________________________________________
Estimated speed
_______________
_______________
Was an oral warning given at the scene?
YES
NO
Position on Road
_______________
_______________
If “Yes” give details _______________________________________________
Was horn sounded?
_______________
_______________
__________________________________________________________________
What lights were used?
_______________
_______________
Please state: Name and Number of Garda/Officer (if known)
Was the accident reported to The Gardaí?
YES
NO
__________________________________________________________________
Did they take statements?
YES
NO
Address of Garda/Police Station ____________________________________
__________________________________________________________________
Was either driver breathalysed?
YES
NO
5. OTHER PARTIES (OWNERS, DRIVERS ETC.)
Name and address of Driver or Owner
Vehicle Registration
Extent of Damage
Insurance Company and Policy No. (if known)
_____________________________________
___________________
_____________________
______________________________________________
_____________________________________
___________________
_____________________
______________________________________________
_____________________________________
___________________
_____________________
______________________________________________
_____________________________________
___________________
_____________________
______________________________________________
_____________________________________
___________________
_____________________
______________________________________________
6. PASSENGERS IN INSURED’S VEHICLE (if more than three, please supply details separately)
Full name
1._________________________________
2. _________________________________
3. ____________________________________
Address
__________________________________
___________________________________
______________________________________
__________________________________
___________________________________
______________________________________
__________________________________
___________________________________
______________________________________
State where seated
Front seat
Rear Seat
Front seat
Rear Seat
Front seat
Rear Seat
Was seat belt worn?
YES
NO
YES
NO
YES
NO
7. INJURED PERSONS: (if more than three, please supply details separately)
Full name
1._________________________________
2. _________________________________
3. ____________________________________
Address
__________________________________
___________________________________
______________________________________
__________________________________
___________________________________
______________________________________
__________________________age ____
___________________________age ____
______________________________age ____
Was this person:
removed to hospital?
YES
NO
YES
NO
YES
NO
detained in hospital?
YES
NO
YES
NO
YES
NO
8. WITNESSES (if more than three, please supply details separately)
Full name
1._________________________________
2. _________________________________
3. ____________________________________
Address & Tel No.
__________________________________
___________________________________
______________________________________
__________________________________
___________________________________
______________________________________
__________________________________
___________________________________
______________________________________
(state if independent)
YES
NO
YES
NO
YES
NO
9. FULL DESCRIPTION OF ACCIDENT (if insufficient space please supply details separately)
_________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
10. SKETCH PLAN OF ACCIDENT:
Please make a rough plan of the road, showing positions of vehicles
and persons concerned. An arrow should indicate the direction
in which they were moving
Who or what, in your opinion, was the cause of the accident?
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
_________
AIG Europe Limited is classified as a “Data Controller” under Irish Data Protection Legislation. By providing your Personal Information to AIG or Personal
Information regarding other individuals you represent that you have the authority to do so and consent to the collection and processing (including the disclosure and international transfer)
of this Personal Information as stated in the Privacy Policy which is available at , by e-mailing or by writing to the Data Protection Officer at AIG Europe
Limited, Ireland Branch, 30 North Wall Quay, International Financial Services Centre, Dublin 1.
I/We hereby certify the foregoing particulars to be true and complete in every respect. I/we understand that the information given
on this form may be submitted to solicitors for use in connection with any litigation arising out of this accident.
Signature of Insured: ____________________________________________________________Date ________________________________
(If a company or firm, give status of signatory):
AIG Europe Limited is authorised by the Prudential Regulation Authority of the United Kingdom, and is regulated by the Central Bank of Ireland for conduct of business rules.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business