Carlow Town Council Accident Claim Form (Page 2 of 2) in pdf

Carlow Town Council Accident Claim Form Page 2

Extent of damage:

Details of repairer:

Details of where vehicle may

Be inspected by an independent

Motor Assessor

If vehicle has been repaired, details

of where the damaged parts may be

inspected by an independent Motor

Assessor:

4. Personal Injury Claims:

If you attended a doctor, A&E department or any other hospital for treatment, please identify the facility that you

attended and the doctor that treated you.

Details of Injury:

Please identify your GP and any other Doctors that are treating you:

Please note: If you have completed an Injuries Board Form, please forward a copy and also your Medical Report.

Supporting Documentation:

Please attach, where appropriate the following documentation with this form

•

Photographs of the accident location. (If photograph isn’t dated, please state the date on which the

photographs were taken)

•

Estimate/ invoice to support the special damages claim that you are making.

•

Any other information which you deem relevant to your claim.

5. Declaration

I declare that the information given in this form is correct to the best of my knowledge.

Claimants Signature: ______________________________________

Date:

______________________________________

Carlow Town Council Accident Claim Form Page 2