Accident Statement
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1ACCIDENT STATEMENT
1.
Date of accident
Time:
2.
3.
Injury(es) even if slight
Locality:
Place: . . . . . . . . . . . . .
Country: . . . .
. . . . . . . . . . . . . . . .
no
yes
4.
Material damage
5.
Witnesses: names, addresses, tel.: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
other than to vehicles A and B objects other than vehicles
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
no
yes
no
yes
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
VEHICLE A
VEHICLE B
12. CIRCUMSTANCES
6.
Insured/policyholder
6.
Insured/policyholder
(see insurance certificate)
(see insurance certificate)
Put a cross in each of the relevant
boxes to help explain the drawing
NAME: ..........................................................................
NAME: ..........................................................................
A
B
* delete where appropriate
First name: ....................................................................
First name: ....................................................................
Address: ........................................................................
Address: ........................................................................
* parked/stopped
1
1
Postal code: ................ Country: ..................................
Postal code: ................ Country: ..................................
* leaving a parking place/
2
2
opening the door
Tel. or E-mail:
Tel. or E-mail:
entering a parking place
7.
Vehicle
3
3
7.
Vehicle
MOTOR
TRAILER
MOTOR
TRAILER
emerging from a car park,
4
4
Make, type
Make, type
from private ground, from a track
........................................
........................................
entering a car park,
5
5
Registration N°
Registration N°
private ground, a track
Registration N°
Registration N°
........................................
........................................
........................................
........................................
entering a roundabout
6
6
Country of registration
Country of registration
Country of registration
Country of registration
........................................
........................................
........................................
........................................
7
7
circulating a roundabout
8.
Insurance company
8.
Insurance company
(see insurance certificate)
(see insurance certificate)
striking the rear of the other vehicle
8
8
while going in the same direction
NAME: ...........................................................................
NAME: ...........................................................................
and in the same lane
Policy N°: ......................................................................
Policy N°: ......................................................................
going in the same direction
9
9
Green Card N°: .............................................................
Green Card N°: .............................................................
but in a different lane
Insurance Certificate or Green Card valid
Insurance Certificate or Green Card valid
10
10
changing lanes
from:
to:
from:
to:
Agency (or bureau, or broker): ......................................
overtaking
Agency (or bureau, or broker): ......................................
11
11
NAME: ...........................................................................
NAME: ...........................................................................
12
12
turning to the right
Address: ........................................................................
Address: ........................................................................
13
13
turning to the left
......................... Country: .............................................
......................... Country: .............................................
14
14
reversing
Tel. or E-mail:
Tel. or E-mail:
Does the policy cover material damage to the vehicle?
encroaching on a lane reserved for
Does the policy cover material damage to the vehicle?
15
15
circulation in the opposite direction
no
yes
no
yes
coming from the right
16
16
(at road junctions)
9.
Driver
9.
Driver
(see driving licence)
(see driving licence)
had not observed a right
NAME: ..........................................................................
NAME: ..........................................................................
17
17
of way sign or a red light
First name: ....................................................................
First name: ....................................................................
Date of birth: ................................................................
Date of birth: ................................................................
Address: ........................................................................
Address: ........................................................................
state number of boxes
......................... Country: .............................................
......................... Country: .............................................
marked with a cross
Tel. or E-mail:
Tel. or E-mail:
Must be signed by both drivers
Does not constitute an admission of liability, but a summary of identities
Driving licence n°: .........................................................
Driving licence n°: .........................................................
and of the facts which will speed up the settlement of claims
Category (A, B, ... ): ......................................................
Category (A, B, ... ): ......................................................
13.
Sketch of accident when impact occurred
13.
Driving licence valid until: .............................................
Driving licence valid until: .............................................
Indicate: 1. the layout of the road - 2. by arrows the direction of the vehicles A, B -
3. their position at the time of impact - 4. the road signs - 5. names of the streets or roads
10.
Indicate the point of
10.
Indicate the point of
initial impact to vehicle A
initial impact to vehicle B
by an arrow
by an arrow
Visible damage
11.
11.
Visible damage
to vehicle A:
to vehicle B:
...........................................
...........................................
...........................................
...........................................
...........................................
...........................................
14.
My remarks:
14.
My remarks:
Signatures of the drivers
15.
15.
.....................................................................................
.....................................................................................
.....................................................................................
.....................................................................................
A
B
.....................................................................................
.....................................................................................
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