Carlow Town Council Accident Claim Form

Small Claims Form

Important Note: The Council will only investigate claims where this form has been fully completed and where the

correct supporting documentation is enclosed. PLEASE USE BLOCK CAPITALS.

1. Claimant Details

Full Name and Address

Telephone Number:

Email Address:

2. Accident Details

Exact Location of Accident:

Date of Accident:

Time of Accident:

Description of Accident:

Was Accident reported to Council? Tick Yes / No

If yes please provide full name of the official

Involved and the Date Notified:

Was Accident reported to the Gardai? Tick Yes / No

If yes please provide full name of the Garda

and the Garda Station involved:

Were there any witness(es)? Tick Yes / No

If yes please provide full name, Address and

telephone number of witness(es)

3. Where Accident relates to a Motor Vehicle:

Make and Model of Vehicle:

Vehicle Registration:

Insurance Company Details:

Motor Tax Expiry Date:

Date of NCT:

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Parent category: Legal