Motor Vehicle Accident Report Form
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1
2AIG EUROPE LIMITED
MOTOR VEHICLE ACCIDENT REPORT
30 North Wall Quay, International Financial
FORM
Services Centre, Dublin 1.
- Please complete all sections -
Tel: +353 1 208 1400 Fax: +353 1 283 7773
NOTE: Any third party correspondence or proceedings
E-Mail:
received must be forwarded immediately to us.
3. VEHICLE
1. INSURED
Vehicle Reg. No.
H.P . or C.C
Make & Model
Name
Year of Make
Present Mileage
Address
Total seating capacity
How many passengers
Was trailer
including driver’s seat
were being carried?
attached?
Yes
No
Occupation ___________________________________________________
For what precise purpose was the vehicle being used?
______________________________________________________________
Home Tel. No: _____________________ E-mail ___________________
Estimated value of vehicle at time of accident __________________
Business Tel. No: _____________________________________________
Is the vehicle:
(a) Owned by the Insured?
Yes
No
Policy No
If “No” give name & address of registered owner?
Broker/Agent
__________________________________________________________
(b) Registered in the Insured’s name?
Yes
No
Are you registered for VAT?
YES
NO
If “No” give name of registered person
2. DRIVER
__________________________________________________________
(c) Hired or Leased?
Yes
No
Name ________________________________________________________
If “Yes” give name of Leasing or Hire Company
Occupation ___________________________________________________
__________________________________________________________
Address ______________________________________________________
Has the vehicle been altered or modified
in any way?
Yes
No
______________________________________________________________
If “Yes” please give details ____________________________________
Home Tel. No: ______________ Business Tel. No: ________________
______________________________________________________________
Age ________ Date of Birth
D ________/ M __________/ Y _______
Damage to the Insured Vehicle
Driving Licence No: ___________________________________________
Did your vehicle sustain any damage?
Yes
No
Date of Expiry
D ________/ M __________/ Y _______
If “Yes” please give details of visible damage___________________
______________________________________________________________
Type of Licence Held:
FULL
PROVISIONAL
______________________________________________________________
If “Full” please state place
______________________________________________________________
and date when test passed:____________________________________
Please state name and address of repairers
If “Provisional” please state length of driving experience:______years
where vehicle may be inspected _______________________________
Has the driver ever been convicted
______________________________________________________________
of any driving offence
YES
NO
______________________________________________________________
If “yes” give details (dates, offences and penalties) _____________
______________________________Phone No.______________________
______________________________________________________________
Is the vehicle at the repairer now?
Yes
No
______________________________________________________________
If “No” when will it be taken there? ____________________________
Has the driver been involved in any
previous accident in the last 5 years
YES
NO
4. ACCIDENT
If “yes” give details ___________________________________________
Time______
a.m.
p.m.
Date
D______ / M______ /Y______
______________________________________________________________
Exact place_______________________________________________________
If driver other than owner, does he/she own a vehicle?
YES
_________________________________________________________________
NO
_________________________________________________________________
If “Yes” state type of vehicle: __________________________________
W
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W
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Insurers of vehicle ____________________________________________
the width of
the weather
lights
Yes
h t
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R
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?
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n
? s
o
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?
No
AIG Europe Limited is classified as a ‘Data Controller’. Please see overleaf.
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