POLICYHOLDER DETAILS Policy Number: Name of Insured/Trading Title Claim Ref: Date of Birth: Email Occupation/Business Daytime Are you registered for VAT? Yes No If Yes please state VAT reg. no. PERSON DRIVING OR PERSON LAST IN CHARGE OF THE VEHICLE AT THE TIME OF INCIDENT Name: Date of Birth: Tel No: Mobile No: Occupation: If driver other than owner, does he/she own a car: Yes No If Yes : Insurer State the relationship of the driver to the policyholder e.g. employee, spouse, friend: How long has the driver been using the vehicle: State type of licence held: Full/ Provisional/ EU Licence Number: Licence operative from: To: Which category is the driver licensed to driver (please tick) A B C C1 D D1 EB EC EC1 ED ED1 F G W Penalty Points Has the Policyholder or driver every had any penalty points imposed for a motoring offence: Yes No If yes; A. State total number of points incurred. B. Give details including dates of the circumstances of each and every offence. Has the Policyholder or Driver ever been? 1. Refused motor insurance, renewal or had special terms imposed? Yes No 2. Convicted of a motoring offence Yes No 3. Convicted of a criminal offence Yes No 4. Involved in a previous motor accident Yes No Does the Policyholder or Driver suffer from any physical or mental disability? Yes No If Yes to any of the questions please give details Page 1
VEHICLE DETAILS Motor Accident Report Form Reg Number: Year: Make: Model: H.P/C.C. Estimated Value of the vehicle at the time of the accident: Nature of Damage: Was there a trailer attached at the time of the accident: State the weight and nature of goods carried if any? Where the vehicle may be inspected? In whose name is the vehicle registered? Does the registered owner solely own the vehicle? Yes/No If No give details: State Owner Insurers: Owner Policy Number: Is the vehicle the subject of any hire, lease or finance agreement (including Hire Purchases) Yes No Name, Address & Reference of the company: DAMAGE TO THE INSURED VEHICLE Full details of damage: Is the Vehicle still in use (i.e. mobile and road-worthy): Estimate Cost of Repairs in Euro: When and where can the vehicle be examined? (please include phone number if possible) PASSENGERS IN YOUR VEHICLE Please confirm the names, addresses and telephone numbers of all passengers in your vehicle: WITNESS DETAILS Name, Address & Contact Telephone Number of any Witnesses: Please indicate which, if any, of these witnesses are in your employment or if you know them: If particulars of incident were taken by Gardaí, give name of Garda and Station Page 2
DESCRIPTION OF INCIDENT Date: Location: Time: Weather Condition: Road Condition: Visibility Condition: Lighting Conditions: Speed Limit Speed before Impact: Insured Third Party: Speed at Impact: Insured Third Party: Width of road: Road markings e.g. broken lines, single white line: What lights was your vehicle displaying? What light was the Third Party displaying? Was the drivers view obstructed in any way? Yes No If Yes give details: Was your vehicle on the correct side of the road: Before Impact: After Impact: Was there debris on the road? Yes No If so whose side: How far away was the other party when first visible to the driver? What signals were given by Insured/ Third Party Insured: Third Party: (horn/ hand/ indicators)? Garda Name: Garda Number: Garda Station: Did the Gardaí attend the scene of the accident? Yes No Did the Gardaí who attend the scene express any opinion as to who was to blame? Yes No If Yes give details: Did you make a written statement? Yes No Was anybody cautioned? Yes No If Yes please give details: Were alcohol/drugs in any way a contributing factor in the accident? Yes No Was either driver breathalysed? Yes No If Yes give details Has a notice of intention to prosecute been given or summons received? Yes No If Yes give details Page 3
DESCRIPTION OF INCIDENT Motor Accident Report Form Written Description of Incident Please give as much information as possible to help us assess liability. Please confirm exactly how the incident happened and confirm details of all damaged property. Please provide a sketch of the incident and include the width of the roads, type and position of all road signs & markings, direction of travel of all parties and the points of impacts(s) In your opinion who is to blame for the accident and why? Page 4
OTHER PARTIES INVOLVED OR PROPERTY INVOLED(if more than 3 please supply details separately) Name of Owner: Address of Owner Name of Driver: Address of Driver: Vehicle Make, Model & Registration Number: Describe nature of damage: Name of Insurer: Policy Number: Vehicle or Property No. 1 Vehicle or Property No 2. Vehicle or Property No. 3 OTHER PARTIES INVOLVED OR PROPERTY INVOLED(if more than 3 please supply details separately) Name & Age: 1 2. 3 Describe Nature & Extent of Injury/ Injuries: Did the injured party/ parties receive medical treatment at the scene: Was person(s) hospitalised: State if driver/ passenger/ pedestrian/ cyclist: If passenger state in which vehicle insured/ TP Was the person(s) wearing a seatbelt: Yes/ No Yes/ No Yes/ No I/ We declare that the foregoing statements are true and correct in every respect and I/We undertake to tender every assistance in my/our power in dealing with the matter. I/We understand that the Information given on this form may be submitted to Solicitors appointed by Patrona Underwriting Ltd, for use in connection with any claim, litigation or threat thereof arising out of this incident. Date: Signature: PLEASE FORWARD ANY THIRD PARTY CORRESPONDENCE UNANSWERED ATTACH ANY PHOTOS OF INCIDENT Page 5