Fill and Sign the Ak Affidavit Form

AIG EUROPE AIG Europe (Ireland) Limited AIG House Merrion Road Dublin 4 Tel: 2081400 Fax: 2837773 E-Mail: postmaster@aig.ie MOTOR CAR ACCIDENT REPORT FORM - Please complete all sections NOTE: Any third party correspondence or proceedings received must be forwarded immediately to us. NOTE: The issue of this form does not constitute an admission of liability under the Policy. 3. VEHICLE 1. INSURED Vehicle Reg. No. Name Year of Make Address H.P. or C.C. Make & Model Present Mileage Total seating capacity How many passengers including driver’s seat were being carried? Was trailer attached? s Yes Occupation ______________________________________________ Home Tel. No: ____________________________________________ s No For what precise purpose was the vehicle being used? _______________________________________________________ Estimated value of vehicle at time of accident __________________ Business Tel. No: _________________________________________ Is the vehicle: s Yes If “No” give name & address of registered owner? (a) Owned by the Insured? Policy No Broker/Agent s No ____________________________________________________ s YES Are you registered for VAT? (b) Registered in the Insured’s name? s NO s Yes s No If “No” give name of registered person 2. DRIVER ____________________________________________________ Name __________________________________________________ Occupation ______________________________________________ s Yes (c) Hired or Leased? s No If “Yes” give name of Leasing or Hire Company ____________________________________________________ Address _________________________________________________ _______________________________________________________ Home Tel. No: _____________ Business Tel. No: _______________ Age _______ Date of Birth D _______/ M _________/ Y ______ Driving Licence No:________________________________________ Date of Expiry D _______/ M _________/ Y ______ Type of Licence Held: s FULL s PROVISIONAL If “Full” please state place and date when test passed: _________________________________ If “Provisional” please state length of driving experience:______years Had the driver ever been convicted of any Driving Offence Has the vehicle been altered or modified s Yes in any way? s No If “Yes” please give details __________________________________ _______________________________________________________ Damage to the Insured Vehicle s Yes Did your vehicle sustain any damage? s No If “Yes” please give details of visible damage____________________ _______________________________________________________ _______________________________________________________ _______________________________________________________ Please state name and address of repairers where vehicle may be inspected______________________________ s YES s NO _______________________________________________________ If “yes” give details (dates, offences and penalties) _______________ _______________________________________________________ _______________________________________________________ _______________________________________________________ Had the driver been concerned in any previous accident in the last 5 years s YES s NO If “yes” give details ________________________________________ _______________________________________________________ If driver other than owner, does he/she own a car? s YES s NO If “Yes” state type of vehicle:_________________________________ Insurers of vehicle_________________________________________ Insurers Policy No.:________________________________________ __________________________Phone No. ____________________ Is the vehicle at the repairer now? s Yes s No If “No” when will it be taken there? ____________________________ 4. ACCIDENT Time______ s a.m. s p.m. Date D______ / M______ /Y______ Exact place _________________________________________________ ___________________________________________________________ ___________________________________________________________ What was the width of the Road? What were the weather conditions? Were street lights s Yes on? s No 4. ACCIDENT contd. Insured Vehicle Third Party Vehicle If “Yes” give details ____________________________________________ Estimated speed ______________ ______________ ___________________________________________________________ Position on Road ______________ ______________ Was horn sounded? ______________ ______________ What lights were used? ______________ s YES Was an oral warning given at the scene? s NO If “Yes” give details ____________________________________________ ______________ ___________________________________________________________ Please state: Name and Number of Garda/Officer (if known) Was the accident reported to Na Gardaí/Police s YES s NO ___________________________________________________________ Did they take statements? s YES s NO Address of Garda/Police Station__________________________________ Was either driver breathalysed? s YES s NO ___________________________________________________________ 5. OTHER PARTIES (OWNERS, DRIVERS ETC.) Name and address of Driver or Owner _________________________________ _________________________________ _________________________________ _________________________________ _________________________________ Vehicle Registration _________________ _________________ _________________ _________________ _________________ Extent of Damage ___________________ ___________________ ___________________ ___________________ ___________________ Insurance Company and Policy No. (if known) _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ 6. PASSENGERS IN INSURED’S VEHICLE (if more than three, please supply details separately) Full name Address 1. _____________________________ _______________________________ _______________________________ _______________________________ 2. ______________________________ _______________________________ _______________________________ _______________________________ 3. ________________________________ __________________________________ __________________________________ __________________________________ State where seated Was seat belt worn? s Front seat s YES s Front seat s YES s Front seat s YES s Rear Seat s NO s Rear Seat s NO s Rear Seat s NO 7. INJURED PERSONS: (if more than three, please supply details separately) Full name Address 1. _____________________________ _______________________________ _______________________________ ________________________age____ Was this person: removed to hospital? s YES detained in hospital? s YES s NO s NO 2. ______________________________ _______________________________ _______________________________ ________________________age____ 3. ________________________________ __________________________________ __________________________________ ___________________________age____ s YES s YES s YES s YES s NO s NO s NO s NO 8. WITNESSES (if more than three, please supply details separately) Full name Address & Tel No. 1. _____________________________ _______________________________ _______________________________ _______________________________ 2. ______________________________ _______________________________ _______________________________ _______________________________ 3. ________________________________ __________________________________ __________________________________ __________________________________ 9. FULL DESCRIPTION OF ACCIDENT (if insufficient space please supply details separately) ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ 10. SKETCH PLAN OF ACCIDENT: Please make a rough plan of the road, showing positions of vehicles and persons concerned. An arrow should indicate the direction in which they were moving Who or what, in your opinion, was the cause of the accident? ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ ___________________________________________________________________________________________________________________________ I/We hereby certify the foregoing particulars to be true and complete in every respect. I/we understand that the information given on this form may be submitted to solicitors for use in connection with any litigation arising out of this accident. Signature of Insured: ______________________________________________________Date _____________________________ (If a company or firm, give status of signatory):