O LEARY INSURANCE GROUP
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1 PART A - POLICYHOLDERS DETAILS Your name: Your Insurer + Policy Number: Your address: Your address (if any): Your occupation: Phone numbers Daytime: Evening: Mobile: Fax: Are you registered for VAT? No Yes VAT number: PART B - INSURED VEHICLE 1. Vehicle registration number: Year of manufacture: Make: Model: Engine size: 2. Number of seats in the vehicle: 3. Are you still paying for the vehicle under a hire-purchase or leasing agreement? Yes No Give details below. Name of hire-purchase or leasing company: Agreement s reference number: 4. Was a trailer attached to your vehicle at the time of the accident? Yes No 5. Give a brief description of the damage. 6. What was the vehicle being used for at the time? 7. On the diagram below, please show where the vehicle is damaged. 8. Where is the vehicle now? 9. Has this vehicle passed the NCT test? Yes No When? 1
2 PART C - COMERCIAL VECHICLES Fill in this part only if your vehicle is a commercial vehicle. 1. The weight and type of goods carried, if any: 2. Is yours a heavy goods vehicle? No Yes Give details below. Your HGV licence number: Expiry date shown on licence: / / (DD/MM/20YY) 3. Total number of fixed seats (including the driver s seat) in front of vehicle: in back of vehicle: 4. Maximum number of people your vehicle can carry: PART D - DRIVERS DETAILS 1. Driver s full name Title (Mr, Mrs, Ms and so on): First name: Surname: 2. Driver s address: 3. Driver s occupation: 4. Driver s date of birth: / / 5. Does the driver own the vehicle? No Yes 6. If no, does the owner pay the driver to drive the vehicle? No Yes 7. Was the driver driving on the orders of the policyholder? No Yes 8. Was the driver driving with the policyholder s permission? No Yes 9. Has the driver got their own insurance covering this accident? No Yes Give details below. Insurance company: Policy number: Has this accident been reported to the insurance company? No Yes PART E - DRIVER S LICENCE DETAILS 1. How long has the driver held a licence? years months 2. Is the licence: full? provisional? 3. Licence number: 4. Vehicle groups the driver can drive: 5. Date of issue shown on the licence: PART F - CIRCUMSTANCES OF ACCIDENT 1. Where did the accident happen? Date: / / Time: am pm 2. What were the weather conditions like at the time? 3. How fast was your vehicle going? 4. What was the speed limit? 5 Which Garda station was the accident reported to? 6 If a pedestrian was involved, was he or she on a pedestrian crossing? No Yes 2
3 If no, was there a crossing nearby? No Yes 7. Please describe exactly what happened. 8 Do you think that the person driving your vehicle was to blame for this accident? No Yes If no, please give your reasons. PART G - WITNESSES (INCLUDING ALL YOUR PASSENGERS) Witness 1 Witness 2 Witness 3 1. Name: 2. Address: 3. Date of birth: 4. Phone number: 5. Did a member of the Garda take details of the accident? No Yes Give details below. Garda s name: Badge number: Station: 6. Did a Garda witness the accident? No Yes 7. If not, did they see the vehicles before they were moved? No Yes PART H - DETAILS OF ANY OTHER DRIVERS AND PEOPLEINVOLVED AND PROPERTY DAMAGED 1. Was another vehicle involved in the accident? No Yes Give details below. Name and address of the driver of the other vehicle: Registration number of the other vehicle: 3
4 Name and address of the other driver s insurer: Policy number: Apparent damage to the other vehicle: In the boxes below, fill in details of people injured. Your passengers Name: Address: Description of injury: Driver and passengers of other vehicles Name: Address: Description of injury: 4
5 2. In the space below, draw a sketch of the accident showing: the positions of all vehicles involved; people or obstacles involved; the width of roads; and any road signs. PART I - DECLARATION I declare that, as far as I know, the information I have given is true. I authorise you, and any solicitor you appoint, to deal with all matters arising from this incident as you see fit and, if appropriate, admit liability or negligence on my behalf. Date: / / Your signature: 5
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