MOTOR VEHICLE ACCIDENT QUESTIONNAIRE & CHECKLIST
|
|
- Charleen Hutchinson
- 8 years ago
- Views:
Transcription
1 EQUILAW Solicitors Ph: Market House 4 Market Street Muswellbrook NSW 2333 Fax: info@equilaw.com.au equilaw.com.au MOTOR VEHICLE ACCIDENT QUESTIONNAIRE & CHECKLIST Bring this completed questionnaire with you when you attend your first appointment. 1. Personal Details Title: Surname: Given Names: Have you ever been known by another name?: Yes No If yes, provide details: Residential address: Postal address: (if differs) Medicare No. Birth date: Age: Country of birth: Home Ph: Mobile no.: Work Ph: Fascimile: 2. Interpreter Do you need an interpreter to help you with your claim? language? Yes No If Yes, what language 3. Driver s Licence Have you ever held a Driver s Licence? Yes No Year first licenced: Driver s Licence No. Please provide a copy of your Driver s License Has your Licence ever been cancelled or suspended? Yes No If Yes, reason for cancellation or suspension page 1 of 28
2 4. Previous advice in relation to accident Have your previously seen a solicitor in respect to this accident? Yes No If Yes, provide details: Solicitor Firm Name & Address Phone Appt. Date 5. Drivers Licence Have you ever held a Drivers Licence? Yes No Year first licenced: Drivers Licence Number Has your licence ever been cancelled or suspended? Yes No Reason for cancellation or suspension: 6. Employment What was your employment situation before the accident? Self employed Full Time Part Time Retired Casual Student/child Home Duties Not Working Other (provide details) Pensioner (provide details) Details: Have you lost income because of the accident? Yes No Are you still losing income? Yes No page 2 of 28
3 6. Employment continued Is the work you do, or are your weekly earnings different, because of the accident? Yes No If Yes, Please provide details below: How many separate periods of time have you been away from work because of the accident? (include short periods when you went for treatment or rehabilitation) Work time lost (weeks/days/hours) Date from Date to Have you returned to work? Yes No If No, when do you expect to return to work? Don t know Employment details Name of Employer Contact person s name Contact Ph Workplace address: Usual weekly working hours: per day: per week: Usual weekly earnings (including overtime, regular bonuses & commission): Description of duties: Do you have a contract of employment? Yes No - If Yes, please provide a copy. page 3 of 28
4 6. Employment continued Were there any periods in which you were acting in a higher position? Yes No - If Yes, please provide details: Are you covered by an Award? Yes No - If so, please provide a copy. Were there any changes to the Award during the period claimed? Yes No - If yes, please provide copies of any previous Awards. Do you have a copy of your last payslip prior to the accident? Yes No - If yes, please provide a copy. Did you change jobs during the period claimed? Yes No - If yes, please provide details: Second job Did you have a second job before the accident? Yes No Name of Employer Contact person s name Contact Ph Workplace address: Usual weekly working hours: per day: per week: Usual weekly earnings (including overtime, regular bonuses & commission): Description of duties: Do you have a contract of employment? Yes No - If Yes, please provide a copy. Were there any periods in which you were acting in a higher position? Yes No - If Yes, please provide details: Are you covered by an Award? Yes No - If so, please provide a copy. Were there any changes to the Award during the period claimed? Yes No - If yes, please provide copies of any previous Awards. page 4 of 28
5 6. Employment continued Do you have a copy of your last payslip prior to the accident? Yes No - If yes, please provide a copy. Did you change jobs during the period claimed? Yes No - If yes, please provide details: Self Employment Have you lost income from self-employment in your business because of the accident? Yes No Not applicable Name of business Nature of business Workplace address Phone Estimated earnings loss (Give details of how much you believe you have lost and how you calculated the amount. You will be asked to give CTP insurers copies of your taxation returns, group certificates and assessment notices where available.) If you are self employed have you hired anyone to replace you? Yes No If yes, give details of replacement including name, address, duties perfomed and cost. If no, explain why not. If you were self employed, did you have a second job before the accident? Yes No Have you received or will you receive any money for being unable to work because of your injuries? (e.g. sick leave or holiday pay, social security benefits, workers compensation or insurance payment.) Yes No If yes, please provide details: page 5 of 28
6 7. Financial Details Accountant Accountant s Name Phone Address Tax Returns Do you have completed tax returns for the period 5 years to date? Yes No - If Yes, please provide a copy. Financial Advisor Do you have a Financial Advisor? Yes No If Yes, please provide the following details. Financial Advisor s Name Phone Address Super Fund Are you in a Super Fund? Yes No If Yes, please provide the following details. Name of Super Fund Phone Address Bank Details Bank Name Account Name BSB No. Account No. page 6 of 28
7 8. Marital Status Married (legal or defacto) Single Separated Divorced Widowed If you are married, do you have a copy of your Marriage Certificate? Yes No - If Yes, please provide a Certified Copy of your Marriage Certificate to this firm. Spouse s Name Spouse s Birth Date Spouse Employed? Yes No Name of Spouse s Employment Spouse s Workplace Address Spouse s Gross Weekly Earnings Spouse s Nett Weekly Earnings 9. Children Do you have Dependent Children? Yes No Name Date of Birth 10. Tertiary Education or Qualifications Do you have a tertiary education? Yes No Institute Year Qualification page 7 of 28
8 11. Details of Accident Time Date Location Street Name Were you carrying out duties for your employer at the time of the accident? Yes No If so, please provide name and address of employer: Have you made a claim for Workers Compensation? Yes No If yes, please provide details of the Workers Compensation Insurer. Have you been given a Workers Compensation Claim Number? Yes No If so, please provide Claim Number Have you received weekly payments of compensation? Yes No If yes, please provide details of your payments below. Are you required to wear prescription glasses while driving? Yes No - If the answer is Yes to the question above, were you wearing your glasses at the time of the accident? Yes No Do you require a hearing aid? Yes No - If the answer is Yes to the question above, were you wearing a hearing aid at the time of the accident? Yes No Were you a driver or a passenger in the motor vehicle? If you were a driver or passenger, was a seat belt fitted to the vehicle? Yes No If you were a driver or a passenger, were you wearing a seat belt? Yes No If you were on a motorbike or a bicycle, were you wearing a helmet? Yes No Had you taken any drugs, including medication or alcohol in the 12 hours before the accident? Yes No page 8 of 28
9 11. Details of Accident continued If you were a passenger in a motor vehicle or a passenger on a bicycle or motorbike, had the driver or rider taken any drugs, including medication or alcohol in the 12 hours before the accident? Yes No - If so, please give details below Please provide a description of the accident (including who you consider caused the accident and how the accident happened. page 9 of 28
10 11. Details of Accident continued Draw a diagram of the accident. Include intersections, streets, roads and their names. Show the point of impact and position of all motor vehicles. page 10 of 28
11 11. Details of Accident continued Lane Markings Yes No Gradient Curve Intersection Yes No Traffic Lights Yes No Sealed Road Yes No Gravel Road Yes No Head Lights Yes No Street Lights Yes No Direction you were travelling Direction other vehicle was travelling Estimated speed on impact of your vehicle Estimated speed on impact of other vehicle Did you use your horn? Yes No Did the other driver use their horn? Yes No Skid Marks Yes No How long were the skid marks? Position where vehicles came to rest Did you take any evasive action to avoid the collision? Yes No - If the answer is Yes to the question above, what evasive action did you take? What was the reason for your journey at the time of the collision? page 11 of 28
12 11. Details of Accident continued What time did you start your journey? am pm Where had you been on the day or evening prior to the collision? What in your opinion was the condition of the road surface at the collision scene? What was your speed 100 metres prior to the collision? What was our speed 50 metres prior to the collision? At the time of the collision, what was your speed? km/h km/h km/h When did you first see the other vehicle involved in the collision? What was the position of this other vehicle on the road? What was your position/distance on the road in relation to the left hand kerb? Were any warning signs made by either driver? Yes No - If the answer to the question above is Yes, please provide detail. How well do you know the section of road where the collision occurred? How often do you travel this section of road? What were the weather conditions at the time of the collision? page 12 of 28
13 11. Details of Accident continued In your opinion, who was responsible for this collision? Please provide a reason for your answer to the question above. 12. Motor Vehicles Involved in the Accident How many motor vehicles were involved in the accident? Do you know the registration number of the motor vehicle you consider caused the accident? Yes No If so, complete Section A below: A. Details of Motor vehicle considered to have caused the accident Registration number Make or model (eg Toyota Camry) Type (eg station wagon, sedan) Year of manufacture Colour Number of people in vehicle Driver s Licence Number & State Briefly describe the damage caused to this vehicle (if known). Name of property damage or comprehensive insurer (if known). page 13 of 28
14 12. Motor Vehicles Involved in the Accident continued Driver s surname/family name Driver s given name(s) Driver s home phone Driver s work phone Driver s mobile phone Driver s Address Owner s surname/family name Owner s given name(s) Owner s home phone Owner s work phone Owner s mobile phone Owner s Address Were you travelling in this vehicle? Yes No - If no, provide details of the vehicle you were travelling in - Section B B. Details of vehicle you were travelling in Registration number Make or model (eg Toyota Camry) Type (eg station wagon, sedan) Year of manufacture Colour Number of people in vehicle Driver s Licence Number & State Briefly describe the damage caused to this vehicle (if known). page 14 of 28
15 12. Motor Vehicles Involved in the Accident continued Name of property damage or comprehensive insurer (if known). Driver s surname/family name Driver s given name(s) Driver s home phone Driver s work phone Driver s mobile phone Driver s Address Owner s surname/family name Owner s given name(s) Owner s home phone Owner s work phone Owner s mobile phone Owner s Address C. Other vehicle involved in the accident Provide details of any other vehicle(s) involved in the accident Registration number Make or model (eg Toyota Camry) Type (eg station wagon, sedan) Year of manufacture Colour Number of people in vehicle Driver s Licence Number & State Briefly describe the damage caused to this vehicle (if known). page 15 of 28
16 12. Motor Vehicles Involved in the Accident continued Name of property damage or comprehensive insurer (if known). Driver s surname/family name Driver s given name(s) Driver s home phone Driver s work phone Driver s mobile phone Driver s Address Owner s surname/family name Owner s given name(s) Owner s home phone Owner s work phone Owner s mobile phone Owner s Address D. Complete this section if you were driving a vehicle at time of accident If you are not the registered owner of the vehicle, did you have permission from the registered owner to be driving this vehicle? Yes No In what mechanical condition was the vehicle you were driving? Were you aware of any mechanical defects with this vehicle? Yes No E. Other Driver Was the other driver in the apparent employ of another person? Yes No If so, whom? Did the other driver appear to be under the influence of alcohol? Yes No page 16 of 28
17 13. Pedestrian If you were a pedestrian did you attempt to cross the road via traffic lights? Yes No Did you attempt to cross the road on a pedestrian crossing? Yes No In which direction were you looking as you crossed the road? Left Right Please describe in detail the point of impact of the car with you? Please describe the impact were you struck front on, or was it a glancing type impact? What part of the vehicle struck you? Where on the roadway did you come to rest? Did you come to rest in front of the vehicle or behind it? What are your recollections following the accident? page 17 of 28
18 14. Witnesses to the Accident and Others Involved Were there any passengers with you in your vehicle at the time of the collision? Yes No If the answer is Yes to the question above, please provide their names. Name Address Phone Were there any passengers in the other vehicle at the time of the collision? Yes No If the answer is Yes to the question above, please provide their names.. Name Address Phone Were there any other person/s who witnessed the collision? Yes No If the answer is Yes to the question above, please provide their names. Name Address Phone page 18 of 28
19 15. Police Was the accident reported to a Police Station? Yes No If so, when and to whom? Date Name Station Event Number Did the Police come to the accident scene? Yes No Did you make a statement to the Police? Yes No - If so, please provide a copy. Did any one else make statements? Yes No - If so, whom? (Please provide copies if you have them) If the answer is Yes to the question above, please provide their names. Name Address Phone Did you sign the Police Officer s Note Book? Yes No Were any charges laid against you? Yes No Were any charges laid against the other drivers? Yes No Provide details of who charges were laid against. Name Registration Plate Number Charge (if known) page 19 of 28
20 15. Police continued Are you aware of the current status of the investigation into the accident? Yes No If yes, please provide details. Did the matter proceed to Court? Yes No Provide details of the Court (if known) Do you recall any conversations that you had with the police officers at the scene? Yes No Please provide details of the conversation below. What comments did they make to you in regards to who s fault the accident was? 16. Medical Ambulance Did you require an ambulance on the day of the accident? Yes No Do you recall any conversations that you had with the ambulance officers treating you at the scene? If so please outline what those conversations were. Yes No page 20 of 28
21 16. Medical continued Hospital Did you go to a hospital after the accident? Yes No If so, which hospital? Were you treated at the hospital? Yes No Date treated Were you admitted to the hospital? Yes No Date admitted Have you been discharged from the hospital? Yes No Date discharged Medical Treatment Before the Accident Name of your normal Medical Practitioner: Please list all Medical Practitioners you have seen in the last 5 years: Name Speciality Name, Address & Phone No. of Surgery Treatment ongoing? (Yes/No) page 21 of 28
22 16. Medical continued Medical Treatment Since the Accident Please list all medical treatment providers you have seen since the accident, including GP s, specialists, hospitals, physiotherapists, chiropractors and any other treatment providers. Name Speciality Name, Address & Ph of Surgery Treatment ongoing? (Yes/No) Have you had any x-rays, CT scans or investigations undertaken since the accident? Yes No If so, please provide details below. Date Type Where - If so, please provide copies of all reports, documents, x-rays, CT Scans or any other investigations in relation to medical treatment since the accident. Have you received any Medical or Workcover Certificates? Yes No - If so, please provide copies of these Certificates. Have any treatment or rehabilitation plan(s) that has been developed for you? Yes No If so, provide details on next page. page 22 of 28
23 16. Medical continued Name Address & Phone number Treatment 17. Out of Pocket Expenses Have you incurred any out of pocket expenses in relation to the accident? (e.g. medical appointments, travel to and from appointments, pharmacy expenses) Yes No - If yes, please provide details below AND provide us with copies of receipts. Date Details of Out of Pocket Expenses Paid or Un (tick) page 23 of 28
24 17. Out of Pocket Expenses continued Have you incurred any out of pocket expenses in relation to the accident? (e.g. medical appointments, travel to and from appointments, pharmacy expenses) Yes - If yes, please provide details below AND provide us with copies of receipts. No Date Details of Out of Pocket Expenses Paid or Un (tick) page 24 of 28
25 18. Injuries Please list your injuries from the accident. (List all injuries and affected areas of the body) How do these injuries affect you now? (The effect of your injuries may change over time) Previous Injuries Have you had any other injuries, disability or illness, before or since the accident to the same part(s) of your body? Yes No If yes, please provide details below Date Injury or Illness Treatment Doctor s Name Address (practice or surgery) Have you ever made a claim for personal injury compensation, workers compensation or other damages? (eg.slip & fall, assault, medical negligence, motor accident) Yes No If yes, please provide details below. Date of Injury Insurance Company Claim or Reference no. Type of Claim page 25 of 28
26 19. Care Have you required personal assistance or care at home since the accident? Yes No If so, who provided this assistance? Please provide details of the hours that person spent assisting you. Phone Name Address (home, work & mobile) Dates & Hours per day Have you required assistance around the house, including cleaning, gardening, mowing, or any other duties? Yes No If so, who provided this assistance? Please provide details of the hours that person spent assisting you. Name Address Phone (home, work & mobile) Dates & Hours per day Have you required assistance in getting to and from medical appointments? Yes No If so, who provided this assistance? Please provide details of the hours that person spent assisting you. Phone Name Address (home, work & mobile) Dates & Hours per day Have you for any of this assistance? Yes No page 26 of 28
27 20. Photographs Do you have any photographs of the vehicles at the collision scene? Yes No Do you have any photographs of your damaged vehicle? Yes No Do you have any photographs of injuries you received in the collision? Yes No Do you have a recent photograph of yourself? Yes No - If the answer in any of the questions above is Yes, please provide copies 21. Additional information Do you wish to add anything further? Yes No If so, please indicate what you wish to add. 22. Declaration Do you declare the information you have supplied is true and correct to the best of your knowledge and belief? Yes No Signature Witness Dated page 27 of 28
28 23. Checklist Before attending your initial appointment, please ensure that you have attached copies of the following documents, if you have them. Page 1 Driver s Licence Copy of your current driver s licence. Page 3 Employment Copy of your Contract of Employment. Page 4 Employment Copy of your Award. Copy of your last payslip prior to the accident. Pages 4 Second Job Copy of your Contract of Employment. Copy of your Award. Copy of your last payslip prior to the accident. Page 6 Tax Returns Copies of your Tax Returns for the period 5 years prior to the accident to date. Page 7 Marriage Certificate Certified Copy of your Marriage Certificate. Page 19 Police Copy of your Statement to the Police. Copies of anyone else s Statement to the Police. Page 22 Medical Treatment Copies of any x-rays, CT Scans or any other investigations. Copies of any Medical or WorkCover Certificates. Page 23 Out of Pocket Expenses Copies of any receipts that you may hold. Copies of any receipts that you may hold in relation to payments made by the insurer. Page 27 Photographs Copies of any photographs that you may have of the vehicles at the collision scene, damage to your vehicle or your injuries.. A recent passport size colour photograph of yourself. page 28 of 28
WORKERS COMPENSATION QUESTIONNAIRE & CHECKLIST
EQUILAW Solicitors Ph: 02 6542 5566 Market House 4 Market Street Muswellbrook NSW 2333 Fax: 02 6543 4397 info@equilaw.com.au equilaw.com.au WORKERS COMPENSATION QUESTIONNAIRE & CHECKLIST (Attach the Workers
More informationHow To Write A Claim For A Car Accident
Compulsory Third Party Personal Injury Claim tification To claim damages for personal injuries in a motor vehicle accident, please complete this form in BLOCK LETTERS 2. Do you have a solicitor acting
More informationMOTOR ACCIDENT PERSONAL INJURY CLAIM FORM
MOTOR ACCIDENT PERSONAL INJURY CLAIM FORM THIS CLAIM FORM IS APPROVED BY THE MOTOR ACCIDENTS AUTHORITY OF NSW. IT IS TO BE USED FOR CLAIMS MADE UNDER THE MOTOR ACCIDENTS COMPENSATION ACT 1999 FOR ACCIDENTS
More informationMotor Accident Notification Form (MANF)
Motor Accident tification Form (MANF) As prescribed under section 84(2)(a) of the Road Transport (Third-Party Insurance) Act 2008 For Compulsory Third-Party (CTP) Insurance Claims in the Australian Capital
More informationMotor Accident Personal Injury Claim Form
Motor Accident Personal Injury Claim Form HAVE YOU BEEN INJURED IN A MOTOR VEHICLE ACCIDENT? If you have been injured in a motor vehicle accident in New South Wales, you may be able to access benefits
More informationFatality Claim Form. South Australia Compulsory Third Party (CTP)
South Australia Compulsory Third Party (CTP) Fatality Claim Form This form is to be completed by any person who is claiming compensation as a result of a person s death in a motor vehicle accident (please
More informationNotice of Accident Claim Form
Insurer s Claim Reference Number Queensland Compulsory Third Party Insurance (CTP) Notice of Accident Claim Form (Fatal Injury) for accidents occurring on and after 1st October 2000 Motor Accident Insurance
More informationNotice of Accident Claim Form
Insurer s Claim Reference Number Queensland Compulsory Third Party Insurance (CTP) Notice of Accident Claim Form (Non-Fatal Injury) for accidents occurring on and after 1st October 2000 Motor Accident
More informationNotice of Accident Claim Form
Insurer's Claim Reference Number Queensland Compulsory Third Party Insurance (CTP) tice of Accident Claim Form (n-fatal Injury) for accidents occurring on and after 1st October 2000 Motor Accident Insurance
More informationCOMPENSATION TO RELATIVES FORM
MOTOR ACCIDENT COMPENSATION TO RELATIVES FORM THIS CLAIM FORM IS APPROVED BY THE MOTOR ACCIDENTS AUTHORITY OF NSW. IT IS TO BE USED FOR CLAIMS MADE UNDER THE COMPENSATION TO RELATIVES ACT 1897 FOR ACCIDENTS
More informationTime limitation DEBT RECOVERY. Please bring completed Questionnaire and related documents with you during your first appointment
EQUILAW Solicitors Ph: 02 6542 5566 Market House 4 Market Street Muswellbrook NSW 2333 Fax: 02 6543 4397 info@equilaw.com.au equilaw.com.au Date / / Next appt / / File no. Time limitation Locality Court
More informationMotor Vehicle Accident Report Form
Motor Vehicle Accident Report Form 1300 725 788 Your Car, Your Choice Know Your Rights Service & Quality Guaranteed One Call Does It All Owner s Particulars (PLEASE COMPLETE IN BLOCK LETTERS) Full Name
More informationApplication for Benefits under the Motor Accidents (Compensation) Act
Application for Benefits under the Motor Accidents (Compensation) Act Application for Benefits The MAC Act provides a wide range of benefits to compensate people injured in a motor vehicle accident for
More informationInquiry form - Motor Accident Page 1
Inquiry form - Motor Accident Page 1 1. Personal Details i. Full name Date of Birth i Residential address Documents to bring If relevant in your situation : diagram or photo of accident site, police report
More informationAdditional Information Form
Insurer s Claim Reference Number Queensland Compulsory Third Party Insurance (CTP) Additional Information Form Motor Accident Insurance Act 1994 Important Notes: The statements of fact contained in this
More informationApplication for Benefits under the Motor Accidents (Compensation) Act
Application for Benefits under the Motor Accidents (Compensation) Act Application for Benefits The MAC Act provides a wide range of benefits to compensate people injured in a motor vehicle accident for
More information1. Injured Persons Position in in Vehicle (PLEASE PRINT NEATLY USING CAPITAL LETTERS)
Common Law Law Claim Claim Form Form Please answer all all questions and and tick tick boxes boxes where where appropriate. Leaving Leaving a question a question blank blank may may delay delay the processing
More informationFORM 1 PERSONAL INJURIES PROCEEDINGS ACT 2002. NOTICE OF CLAIM (Non-Health Care Claims)
FORM 1 PERSONAL INJURIES PROCEEDINGS ACT 2002 NOTICE OF CLAIM (Non-Health Care Claims) INSTRUCTIONS FOR COMPLETING THIS FORM ARE ATTACHED AS THE LAST THREE PAGES OF THE FORM PLEASE READ INSTRUCTIONS CAREFULLY
More informationFORM 2 PERSONAL INJURIES PROCEEDINGS ACT 2002. NOTICE OF CLAIM (Health Care Claims)
FORM 2 PERSONAL INJURIES PROCEEDINGS ACT 2002 NOTICE OF CLAIM (Health Care Claims) INSTRUCTIONS FOR COMPLETING THIS FORM ARE ATTACHED AS THE LAST THREE PAGES OF THE FORM PLEASE READ INSTRUCTIONS CAREFULLY
More informationTHE SALAZAR LAW FIRM, P.A. NEW CLIENT INFORMATION SHEET (PERSONAL INJURY MOTOR VEHICLE) PERSONAL INFORMATION:
THE SALAZAR LAW FIRM, P.A. NEW CLIENT INFORMATION SHEET (PERSONAL INJURY MOTOR VEHICLE) TODAY'S DATE PERSONAL INFORMATION: DATE OF ACCIDENT NAME HOME ADDRESS CITY STATE ZIP HOME TELEPHONE ( ) DATE OF BIRTH
More informationCan the TAC help you?
Can the TAC help you? The Transport Accident Commission (TAC) pays for the reasonable cost of treatment and support services for people injured in transport accidents. You may be eligible to have medical
More informationApplication for Scheduled Benefits
Application for Scheduled Benefits CLAIM FORM B To be completed by, or on behalf of, an injured driver/ passenger/motorcyclist/pillion passenger/pedestrian/cyclist Please also complete Claim Form A Notice
More informationApplication for Benefits under the Motor Accidents (Compensation) Act Fatal Accident Application
Application for Benefits under the Motor Accidents (Compensation) Act Fatal Accident Application Losing a family member in a motor vehicle accident is a traumatic and difficult experience. The Motor Accidents
More informationClaim form Motor accident
Claim form Motor accident 30 EAGLE STAR INSURANCE COMPANY (IRELAND) LTD CGL 25495 A member of the Zurich Financial Services Group www.eaglestar.ie Motor accident Policy number: Claim number: This form
More informationPERSONAL INJURY/AUTO ACCIDENT QUESTIONNAIRE
PERSONAL INJURY/AUTO ACCIDENT QUESTIONNAIRE TODAY S DATE: PERSONAL INFORMATION: NAME: (home) (cell) Age: Date of Birth: Social Security No: EMPLOYER: (work) Occupation: Worked there how long? Immediate
More informationMotor accident. Claim form. telephone 01 667 0666 fax 01 667 0644 website www.zurich.ie 06/08 FI 44766
Zurich House Ballsbridge park Dublin 4 telephone 01 667 0666 fax 01 667 0644 website www.zurich.ie ZURICH INSURANCE IRELAND LIMITED IS REGULATED BY THE FINANCIAL REGULATOR Claim form Motor accident 30
More informationVEHICLE ACCIDENT CLAIM FORM
Please help us to help you by: completing all relevant questions in full as this can avoid the need for further enquiry and possible delay in settling your claim signing and dating page 7 of this form
More informationO LEARY INSURANCE GROUP
PART A - POLICYHOLDERS DETAILS Your name: Your Insurer + Policy Number: Your address: Your e-mail address (if any): Your occupation: Phone numbers Daytime: Evening: Mobile: Fax: Are you registered for
More informationDetails of Helivac RAC Claim
Details of Helivac RAC Claim A. Claimant details 1. Title: 2. Surname: 3. Name: 4. Date of birth: 5. ID number / Passport number: Note: A certified legible copy of your identity document must be attached
More informationMOTOR VEHICLE ACCIDENT Claim Report
MOTOR VEHICLE ACCIDENT Claim Report HBA General Insurance and Mutual Community General Insurance Insurer: Mutual Community General Insurance Pty Ltd Abn 59 007 895 543 Please retain this page for your
More informationMotor Accident Notification Form
Motor Accident tification Form This form is Approved Form AF2014-59, approved on 26 August 2014 by Karen Doran, delegate of the director-general, under section 276 of the Road Transport (Third- Party Insurance)
More informationMotor Vehicle Accident Claim form
Motor Vehicle Accident Claim form Complaints procedure Enthusiast Underwriting Pty Ltd is a member of the Financial Ombudsman Service. This independent service is provided to the insuring public at no
More informationMotor Vehicle Claim Form
1st Floor, 50 Hindmarsh Square Adelaide SA 5000 PO Box 6095 Halifax St Adelaide 5000 Phone 08 8413 6300 Facsimile 08 82119838 enquiries@brecknock.com.au brecknock.com.au Motor Vehicle Claim Form We re
More informationMOTOR VEHICLE ACCIDENT CLAIM REPORT
MOTOR VEHICLE ACCIDENT CLAIM REPORT CGU Insurance Limited ABN 27 004 478 371 Please retain this page for your information ABOUT YOUR CLAIM Please obtain one quotation for the repair of your vehicle from
More informationMotor Vehicle. Accident Claim Form COMPLAINTS PROCEDURE. Financial Ombudsman Service. Privacy Statement. General Insurance Code of Practice
COMPLAINTS PROCEDURE Enthusiast Underwriting Pty Ltd is a member of the Financial Ombudsman Service. This independent service is provided to the insuring public at no cost and aims to resolve claims complaints
More informationMotor Vehicle. Claim Report
Motor Vehicle Claim Report Please retain this page for your information IMPORTANT INFORMATION ABOUT YOUR CLAIM This form must be completed and signed by the person who was driving your vehicle, or the
More informationHow To Fill Out A Claim Form For A Car Accident In The Uk
Motor Vehicle Claim Report Please retain this page for your information IMPORTANT INFORMATION ABOUT YOUR CLAIM This form must be completed and signed by the person who was driving your vehicle, or the
More informationMotor Vehicle Claim Form
SSAA Insurance Brokers Pty Ltd Phone (08) 8332 0281 The Precinct Freecall 1800 808 608 Suite 14, 539 Greenhill Road Facsimile (08) 8332 0303 539 Greenhill Road Email insurance@ssaains.com.au Hazelwood
More informationCOMMERCIAL MOTOR CLAIM FORM
COMMERCIAL MOTOR CLAIM FORM Please complete in full all sections of this claims form and return it to Insuret as soon as possible after the accident. Unless specifically arranged beforehand, no repairs
More informationCLAIM FORM A. To be completed by the registered operator/ owner or driver of the vehicle
Notice of Accident CLAIM FORM A To be completed by the registered operator/ owner or driver of the vehicle If you have suffered Personal Injury resulting directly from this motor accident and wish to claim
More informationMOTOR VEHICLE ACCIDENT CLAIM FORM
MOTOR VEHICLE ACCIDENT CLAIM FORM Insurer: Insured Identity No.: Occupation: Phone No.: Vehicle Reg No.: Date Purchased: Make: Tare: Gross Vehicle Mass: Kilometers: Price Paid: Value: Year: Model: If the
More informationmotor vehicle motor vehicle insurance for privately owned non-commercial vehicles accident claim report
motor vehicle insurance for privately owned non-commercial vehicles motor vehicle accident claim report Insurer CGU Insurance Limited ABN 27 004 478 371 An IAG Company CGU Insurance Limited ABN 27 004
More informationClaim Form. Journey Report Form. To be completed by Policyholder
This form must be accompanied by an Attending Physicians Statement, which can be obtained by telephoning any of our offices listed. By furnishing this Form the Company makes no admission of Liability or
More informationMOTOR VEHICLE CLAIM FORM
MOTOR VEHICLE CLAIM FORM Dear Policyholder, We re sorry to hear you ve had an accident. Our aim is to settle your claim as quickly as possible. You can help us do this by ensuring the enclosed claim form
More informationYour People, Protected. Personal Accident and Sickness Cover Claim Form
Your People, Protected Personal Accident and Sickness Cover Claim Form Personal Accident and Sickness Cover/Claim Form 2 Personal Accident and Sickness Cover Claim Form IMPORTANT INFORMATION We act upon
More informationClaim Form. Motor Vehicle. Section 1 (To be completed by Owner): Occupation. Name of insured. Address. Phone No [ ] Year Model.
Section 1 (To be completed by Owner): Policy no Name of insured Occupation Expiry Date Phone No [ ] Make of Vehicle Mileage Registration No Year Model Co-Owner In whose name is the registered? For what
More informationPERSONAL ACCIDENT CLAIM FORM
PERSONAL ACCIDENT CLAIM FORM OFFICE USE ONLY Claim Number Reference Number Complete this form if: You have suffered an accident, outside working hours and wish to claim weekly, capital and/or broken bones
More informationDAWES MOTOR INSURANCE MOTOR VEHICLE CLAIM FORM IMPORTANT NOTICES
DAWES MOTOR INSURANCE MOTOR VEHICLE CLAIM FORM PO Box 2717 Taren Point NSW 2229 Telephone: 1300 188 299 Facsimile: 1300 662 215 Email: claims@dawes.com.au www.dawes.com.au Before completing this claim
More informationPersonal Accident Claim Form
Corporate Services Network ABN 30 074 864 609 Level 2 280 George Street Sydney NSW 2000 Ph: 61 2 8256 1770 Fax: 61 2 8256 1775 www.csnet.com.au e-mail: claims@csnet.com.au Personal Accident Claim Form
More informationClaim for Compensation for a Work-related death
SRC 184 (March 2014) Claim for Compensation for a Work-related death This form is to be completed if you wish to claim compensation under the Safety, Rehabilitation and Compensation Act 1988 (SRC Act)
More informationPersonal Accident and Sickness Claim Form
Please return claim form to: Corporate Services Network 2 / 280 George Street Sydney NSW 2000 Ph: +61 2 8256 1770 Fax: +61 2 8256 1775 E-mail: claims@csnet.com.au Employer: Claimants Name: Job Title: Work
More informationYour Accident Fact Kit
Your Accident Fact Kit We hope you find our Accident Fact Kit helpful in the event of an accident. Please be sure to print multiple copies and keep them in the glove compartment of your vehicle in the
More informationAPPLICATION FOR COMPENSATION FORM FOR A PERSONAL INJURY (Do not use this form for claims relating to fatal injuries)
Compensation Services 6th Floor Millennium House 17-25 Great Victoria Street Belfast BT2 7AQ Telephone: 0300 200 7887 Criminal Injuries Compensation Scheme (2009) Made under the Criminal Injuries Compensation
More informationMOTOR VEHICLE CLAIM FORM (Accident or Theft)
Cowden Group MOTOR VEHICLE CLAIM FORM (Accident or Theft) The supply or acceptance of this form is not an admission of liability on the part of your Insurer 1. Your Details Policy No Expiry of Insured
More informationJourney Injury CLAIM FORM. Call ATC Claims for assistance on 1800 994 694. 1. You complete Section A.
INSURANCE SOLUTIONS CLAIM FORM Journey Injury EXTF052 Call ATC Claims for assistance on 1800 994 694 1. You complete Section A. 2. Your Medical Practitioner completes Section B. 3. Your Employer completes
More informationWORKCOVER TOP-UP CLAIM FORM
WORKCOVER TOP-UP CLAIM FORM OFFICE USE ONLY Claim Number Reference Number Complete this form if: You have suffered a workplace accident and have received 52 weeks of WorkCover benefits and wish to claim
More informationHow did you hear about The Mills Law Firm? MVA Premises Liability Labor Law Product Liability Other:
CLIENT QUESTIONNAIRE Name: Date: How did you hear about The Mills Law Firm? Type of Case: MVA Premises Liability Labor Law Product Liability Other: Please answer the following questions with as much detail
More informationPersonal Accident and Sickness Claim Form
Corporate Services Network ABN 30 074 864 609 Level 2 280 George Street Sydney NSW 2000 Ph: 61 2 8256 1770 Fax: 61 2 8256 1775 www.csnet.com.au e-mail: claims@csnet.com.au Employer: Claimants Name: Job
More informationMotor Vehicle Accident Patient Intake Form
Motor Vehicle Accident Patient Intake Form Name: Date of Accident (mm/dd/yyyy): Date of Birth (dd/mm/yyyy) (Cell) Telephone: (Home) (Work) Email: @ Insurance Information: Company Name: Name of Adjustor:
More informationCLIENT QUESTIONNAIRE AUTO INJURY PERSONAL
CLIENT QUESTIONNAIRE AUTO INJURY PERSONAL 1. Full Name: 2. Other Names Known By: 3. Address: 4. Home Phone: Work Phone: 5. Date of Birth: Age: 6. Social Security Number: 7. Marital Status: 8. Spouse (including
More informationMotor Accident Report Form
Motor Accident Report Form Tel: 01423 876000 Rural Insurance Group Limited The Lenz Hornbeam Park Harrogate HG2 8RE Fax: 01423 874127 INSURED Motor Accident Report Form Policy. Name Home Tel.. Work Tel..
More informationYour Accident Fact Kit
Your Accident Fact Kit We hope you find our Accident Fact Kit helpful in the event of an accident. Please be sure to print multiple copies and keep them in the glove compartment of your vehicle in the
More informationMOTOR VEHICLE CLAIM FORM
MOTOR VEHICLE CLAIM FORM Dear Policyholder, We re sorry to hear you ve had an accident. Our aim is to settle your claim as quickly as possible. You can help us do this by ensuring the enclosed claim form
More informationMOTOR ACCIDENT REPORT (NOT FOR USE ON THEFT CLAIMS OR MOTOR TRADE)
Insurance Company Limited MOTOR ACCIDENT REPORT (NOT FOR USE ON THEFT CLAIMS OR MOTOR TRADE) First Response Claims Line 0845 373 1300 Fax 020 7068 7740 Email claims@tradex.com www.tradex.com Policyholder
More informationMOTOR TRADE CLAIM FORM
Insurance Company Limited MOTOR TRADE CLAIM FORM First Response Claims Line 0845 373 1300 Fax 020 7068 7740 Email claims@tradex.com www.tradex.com Policyholder s Name Company Name Policy No. (cover note
More informationCOUNTY OWNED VEHICLE USAGE POLICY. Effective January 1, 2009
COUNTY OWNED VEHICLE USAGE POLICY Effective January 1, 2009 Ohio Revised Code 307.72 states that motor vehicles purchased or leased as provided by section 307.41 of the Revised Code shall be for the use
More informationClaim form Motor Vehicle
Claim form Motor Vehicle The Company does not admit Liability by the issue of this Form. It is issued to enable the Insured to lodge their written statement of claim. CLAIM NUMBER OFFICE USE ONLY Claim
More informationTHE COMPANY DOES NOT ADMIT LIABILITY BY THE ISSUE OF THIS FORM. IT IS ISSUED TO ENABLE THE INSURED TO LODGE THEIR WRITTEN STATEMENT OF CLAIM.
CLAIM FORM Motor Vehicle The Company does not admit Liability by the issue of this Form. It is issued to enable the Insured to lodge their written statement of claim. CLAIM NUMBER OFFICE USE ONLY CLAIM
More informationMotor Vehicle Claim Form
phone: +64 9 377 4314 fax: +64 9 373 4882 email: claims@icib.co.nz web: www.icib.co.nz Level 7, 26 Hobson Street Auckland, PO Box 3174 Auckland 1140, New Zealand Motor Vehicle Claim Form Policy Details
More informationCONVEYANCING QUESTIONNAIRE & CHECKLIST FOR VENDORS SELLING A BUSINESS
EQUILAW Solicitors Ph: 02 6542 5566 Market House 4 Market Street Muswellbrook NSW 2333 Fax: 02 6543 4397 info@equilaw.com.au equilaw.com.au CONVEYANCING QUESTIONNAIRE & CHECKLIST FOR VENDORS SELLING A
More informationMOTOR VEHICLE CLAIM FORM
MOTOR VEHICLE CLAIM FORM How to obtain a quick response to your claim: 1. Make sure that you fully answer all questions 2. Attach a copy of the Driver s Licence for the driver of the vehicle at the time
More informationBeazley Energy Super Income Protection. form. claim
Beazley Energy Super Income Protection form claim Beazley Energy Super Income Protection Claim form Page 2 claim contents form Privacy statement Page 3 Important notice Page 4 Section A Claimants section
More informationClaim for Compensation for a Work-related death
SRC184(Feb2008) Claim for Compensation for a Work-related death This form is to be completed if you wish to claim compensation under the Safety, Rehabilitation and Compensation Act 1988 (SRC Act) for the
More informationMyburgh Attorneys HAVE YOU BEEN INJURED IN A CAR ACCIDENT? DO YOU KNOW SOMEBODY WHO HAS BEEN INJURED IN A CAR ACCIDENT? WHAT ARE YOUR RIGHTS?
Myburgh Attorneys HAVE YOU BEEN INJURED IN A CAR ACCIDENT? OR DO YOU KNOW SOMEBODY WHO HAS BEEN INJURED IN A CAR ACCIDENT? WHAT ARE YOUR RIGHTS? THE ROAD ACCIDENT FUND (RAF) The RAF was created to compensate
More informationClaim Form Road Accident Family Protection Plan (Injury cover)
Claim Form Road Accident Family Protection Plan (Injury cover) Return address and Zestlife contact details: E-mail: info@zestlife.co.za or fax: 021 001 0248 or post to Private Bag X1005, Claremont, 7735
More informationHELPFUL TIPS AFTER A CAR ACCIDENT
HELPFUL TIPS AFTER A CAR ACCIDENT A PRACTICAL GUIDE BY ERIN M. HARGIS, ESQ A car accident can be a very traumatic and stressful event and it may be difficult to think clearly if you have just been involved
More informationSports Injury CLAIM FORM. Call ATC for assistance on 1800 994 694. 1. You complete Section A and B.
INSURANCE SOLUTIONS CLAIM FORM Sports Injury EXTF03520130320 Call ATC for assistance on 1800 994 694 1. You complete Section A and B. 2. If you have a Non Medicare Expense claim, you should also complete
More informationLHMU Accidental Dental Claim Form
LHMU Accidental Dental Claim Form DENTAL BENEFIT CLAIM In order to alleviate any delay in the processing time of your claim, please ensure the following: The claim form is returned with all fields completed.
More informationMotor Vehicle Claim Form
Motor Vehicle Claim Form Dear Policyholder, We re sorry to hear you ve had an accident. Our aim is to settle your claim as quickly as possible. You can help us do this by ensuring the enclosed claim form
More informationWHAT TO DO IN CASE OF A CAR ACCIDENT or SLIP & FALL ACCIDENT
WHAT TO DO IN CASE OF A CAR ACCIDENT or SLIP & FALL ACCIDENT 10 things you must do after a motor vehicle accident How to talk to an insurance claim adjuster The steps you must take after a slip / trip
More informationPREVIEW PLEASE DO NOT COPY THIS DOCUMENT THANK YOU
Form: Personal injury automobile accident case checklist PERSONAL INJURY AUTOMOBILE ACCIDENT CASE CHECKLIST Did you witness the accident? Yes No When? Where? How far were you from the accident? Describe
More informationPersonal Injury Claim Form
ACE Insurance Limited ABN 23 001 642 020 28-34 O Connell Street Sydney NSW 2000 Australia GPO Box 4065 Sydney NSW 2001 Australia 1800 688 640 claims phone 1800 815 675 customer service +61 (0)2 9231 3697
More informationPersonal Injury Claim Form
ACE Insurance Limited ABN 23 001 642 020 28-34 O Connell Street Sydney NSW 2000 Australia GPO Box 4065 Sydney NSW 2001 Australia (02) 9335 3355 main (02) 9231 3697 fax www.aceinsurance.com.au 1800 815
More informationMotor Vehicle Claim Form
Motor Vehicle Claim Form MOTOR VEHICLE CLAIM FORM Dear Policyholder, We re sorry to hear you ve had an accident. Our aim is to settle your claim as quickly as possible. You can help us do this by ensuring
More informationLevel 1, 2 Wellington Parade, East Melbourne. 3002. ph: 03 9235 5255 fax: 1800 633 073 email: enquiries@prorisk.com.au web: www.prorisk.com.
Level 1, 2 Wellington Parade, East Melbourne. 3002. ph: 03 9235 5255 fax: 1800 633 073 email: enquiries@prorisk.com.au web: www.prorisk.com.au Professional Risk Underwriting Pty Ltd ABN 80 103 953 073.
More informationHow To Tell Someone You Were Injured In A Car Accident
Personal Injury Questionnaire Answer each question fully and accurately. Success in this case depends on mutual confidence and complete cooperation between you (as the client) and the attorney. It is imperative
More informationPlaintiff s Interrogatories Directed To Defendant(S)
FIRST JUDICIAL DISTRICT OF PENNSYLVANIA IN THE COURT OF COMMON PLEAS OF PHILADELPHIA COUNTY PLAINTIFF S NAME : Civil Trial Division : : Compulsory Arbitration Program : vs. : : Term, 20 : DEFENDANT S NAME
More informationInformation for people injured in road crashes
Information for people injured in road crashes What is CTP insurance? All South Australian drivers pay a CTP insurance premium when they register their vehicle. The CTP premium provides drivers and/or
More information2. The Insured (Vehicle owner)
mobile plant liability claim form WFI Insurance Limited, ABN 24 000 036 279 The issue of this form must not be taken as an admission of liability. Form is to be completed as far as possible by the driver
More informationCombined Insurance Claim Form
Combined Insurance Claim Form Important Instructions on How to Complete the Attached Claim Form and How We Assess Claims Please read these important instructions on how to complete the attached Claim Form.
More informationAPPLICATION FOR COMPENSATION FORM FOR A PERSONAL INJURY (Do not use this form for claims relating to fatal injuries)
The Compensation Agency Royston House 34 Upper Queen Street Belfast BT1 6FD www.compensationni.gov.uk THE COMPENSATION Agency Reference number For official use only T4 Criminal Injuries Compensation Scheme
More informationPERSONAL INJURY CLAIM FORM
Office use only Policy Number: Claim Number: 01PO527349 PERSONAL INJURY CLAIM FORM INSURANCE BROKER FOR V-Insurance Group Pty Ltd Authorised Representative No. 432898 an authorised representative of Willis
More informationthird party claim form RAF 1
1 personal details of claimant: Title Surname Postal address / Passport number te: A certified legible copy of your identity document must be attached to this claim form Home telephone number Work telephone
More informationNEW YORK STATE BAR ASSOCIATION. LEGALEase. If You Have An Auto Accident SAMPLE
NEW YORK STATE BAR ASSOCIATION LEGALEase If You Have An Auto Accident If You Have An Auto Accident What should you do if you re involved in an automobile accident in New York? STOP! By law, you are required
More informationPersonal Accident Claim Form
Personal Accident Claim Form Claimant Details Title Full Name Date of Birth Occupation Usual Country of Domicile Claimant Address: Contact Details Postcode: Daytime Telephone: Email Address: Wherever possible
More informationNT WORKERS COMPENSATION CLAIM FORM
Information for Workers Guidance to PART 1 of the Claim Form Notify your employer of your injury, verbally or in writing, as soon as practicable. Fully complete PART 1 (questions 1 to 8) of the following
More informationPERSONAL INJURY PARTICULARS
PERSONAL INJURY PARTICULARS Magistrates Court of South Australia (Civil Division) www.courts.sa.gov.au Date Filed: Court Use Form 22 Trial Court Action No Address Street Telephone Facsimile DX BETWEEN
More informationPersonal Injury Claim Form
ACE Insurance Limited ACE Insurance Limited GPO Box 4065 1800 688 640 claims phone ABN 23 001 642 020 ABN 23 001 642 020 Sydney NSW 2001 1800 815 675 customer service The ACE Building GPO Box 4065 Claims
More informationImportant message for customers wishing to make a claim on their policy
Important message for customers wishing to make a claim on their policy Before we can action your claim, can you please : Fully complete the attached claim form If your vehicle is driveable, call us to
More information