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1 You have been injured in an accident Annex 2 GENERAL INFORMATION Claim-file reference (as detailed in accompanying letter):.. Date, location and time of accident:. 1. Personal details First name(s), last name: Date of birth:.. Address: Telephone (home): Telephone (mobile): address: Bank account no.:. Marital status: Single Married Cohabiting Widow/Widower Separated Divorced Name of spouse/cohabiting partner: Date of birth of spouse/cohabiting partner: / / Working status of spouse/cohabiting partner: Full time Part time: hours/week Household composition: First name, last Date of birth Dependent Cohabiting name Spouse/partner Yes No Yes No Child(ren) Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Parent(s) Yes No Yes No Yes No Yes No Is/are the perpetrator(s) of the accident a relation of any kind or a dependent? Yes No If yes, please give details:.

2 2. Working status Have you suffered a loss of income as a result of the accident? Yes No If yes, please provide evidence of your income for the month prior to the accident (e.g. a payslip) Working status as at date of accident Worker (blue-collar) Employee (white-collar) Civil servant/military officer - statutory - contracted Self-employed Student/Child Retired Early retired Jobseeker In receipt of benefit from mutual health-insurance provider In receipt of benefit from CPAS/OCMW Unemployed Other Tick as appropriate Since If you are in paid employment Name and address of your employer:. Contract Full-time Part-time No. of hours/week Wage/salary Gross Taxable Net Per hour Per month Per year Other benefits (bonuses, 13th month, meal vouchers, etc.):...

3 If you are self-employed: as main occupation as secondary occupation Tick as appropriate Taxable income Fixed costs (total) Company director One-person company Independent worker Please enclose tax assessment notices for the past three years. BCE/KBO no.:.. If you are a student: Name of school/college:.. Type and duration of course:. Year of course at time of accident:. 3. Circumstances of the accident Was the incident: an accident at work or on the way to work? an accident at school/college or on the way to school/college? a private accident? If an accident at work or on the way to work: Name and address of your employer's occupational-accident insurer: If an accident at school/college or on the way to school/college: Address of school/college and name and address of school's/college's insurer: Were there any witnesses to the accident? Yes No If yes, please give details (first name, last name and address):.

4 4. Material consequences of the accident Description of damage to items other than a vehicle. Please enclose all receipts/invoices/other evidence and retain any damaged items. Item Description of damage Date of purchase Amount paid for item (Estimate) 5. Bodily injury caused by the accident Nature of injuries:.... Were you admitted to hospital following the accident? Yes No Name of treating doctor and/or clinic:.. If admitted to hospital: Date of admission: / / Date of discharge: / / Have you been completely unable to work? Yes No If yes, from / / to / / Are you still receiving treatment? Yes No Are you completely recovered? Yes No If yes, since / / Please enclose the document Medical Certificate to be completed by your doctor.

5 6. Involvement of associations or insurers Following the accident, did you approach any of the associations/insurers listed below? If yes, please give details in the table. Details of association/insurer Reference Occupational-accident insurer Medical-expenses insurer Hospitalisation insurer Personal-accident insurer Income-protection insurer Material-damage insurer Travel insurer Mutual health-insurance provider (mutualité/mutualiteit) Public Social Assistance Centre (CPAS/OCMW) Other Mutual health-insurance provider (attach a sticker): Do you hold personal/family civil-liability cover? Yes No Do you hold legal-expenses cover? Yes No 7. Comments This questionnaire is not exhaustive. Please forward all other information you consider to be relevant or necessary in respect of your accident. The personal data collected by means of this document is used for the following purposes: managing the claim in question, particularly in terms of recording and assessing the bodily injury sustained by the undersigned or by the person s/he represents; detecting and preventing fraud; and processing for statistical purposes. For these purposes alone, this data may be passed on, if necessary, to other insurance companies concerned by compensation for the bodily injury sustained by the undersigned or of the person s/he represents, to these companies' representative in Belgium, their correspondent abroad, their reinsurers, their claims settlement office, an expert, a lawyer, a technical advisory body, the insurance agent of the undersigned or of the person s/he represents, and more generally, to any

6 person or entity filing an action or against whom an action is filed in connection with the bodily injury mentioned above. The undersigned hereby consents to the use of data on his/her health or that of the person s/he represents when this data is required for management of the claim in question. The undersigned consents to data on his/her health or that of the person s/he represents being used without a healthcare professional being responsible for that use. The undersigned consents to a medical examination, if one is required. Such health-related data is handled with the utmost discretion, and only by authorized people. Those concerned may consult their own data and, if necessary, have it corrected by sending a signed, dated request, along with a copy of both sides of their identity card, to the insurer who requested the information. Further information may be obtained from the same insurer. Within the framework of the compensation procedure, the insurer has to comply with «the rules of conduct for claim settlement: contact with victims of serious accidents» which can be found on Any complaint about the insurance company's failure to respect the code of conduct must be addressed by the consumer to the complaints department of the company concerned, in accordance with the rules of conduct for complaints management in the insurance companies (available on If the consumer considers the answer given by this department to be unsatisfactory, he can lodge the complaint with the Insurance Ombudsman through Done at..... Date: /. /. Name and first name(s) of signatory:. Address:. Capacity: Telephone (home): Telephone (mobile): address: Signature 1 1 If the victim themself is unable to sign, please state reason