Fill and Sign the Cpcc Transcript Request Form

Generali PoisÈovÀa a.s. P.O.BOX 10 Mlynské nivy 1, 820 04 Bratislava 24 Telefón: 02 / 59 33 22 11 Fax: 02 / 59 33 22 00 www.generali.sk infolinka: 0800 123 124 Car accident report This form is for speeding up adjusting your claim. Both drivers should fill in. 1. Date of the accident Hour 2. Location (street No., road km) 3. Injuries? yes 4. Other damages than on cars A and B yes 5. Witnesses (name, address, phone - underline the fellow-travellers) no 5a. Was the claim Investigated by the Police? no yes no By who: 12. Cross the concerns; the car was Vehicle A 6. Insured (name, surname and address) Vehicle B B A 1 2 stopping 3 4 entering the road 4 5 leaving the road 5 6 entering the roundabout 6 7 yes getting going 3 V.A.T. payer 1 2 Telephone (from 9.00 till 16.00) parked going in the roundabout 6. Insured (name, surname and address) 7 Telephone (from 9.00 till 16.00) no 7. Vehicle no 7. Vehicle Make - Type Make - Type Year of Manufacture Year of Manufacture Registration number plate Registration number plate 8. Insurer 8 bumped against the car going in front of you in the same lane 8 8. Insurer Office Address 9 going in the same direction but in a different lane 9 Office Address changing lanes 10 10 Liability Insurance No Liability Insurance No 11 overtaking 11 12 Green card No turning right 12 Green card No Border insurance valid till Border insurance valid till Is the car covered by the motor hull insurance? yes Is the car covered by the motor hull insurance? no 13 turning left pulling back yes 13 14 Insurer 14 9. The driver Surname 15 going on the wrong side of the road 16 coming from the right 16 17 not giving the right of way 17 Number of crosses Surname 15 ➡ Name Name Address Driving license No Class no Insurer 9. The driver ➡ Issued by 10. Use pointer to mark the point of impact Address Driving license No Class Issued by 10. Use pointer to mark the point of impact 13. Accident situation plan Mark: 1. Road, 2. Driving direction of the cars A and B, 3. Position of the cars in the moment of impact, 4. Traffic signs, 5. Street names A B 11. Visible damage 11. Visible damage 14. Notes SK 26.003.01.02 yes V.A.T. payer 15. Signatures of the drivers A A 14. Notes B Do not make any changes after signing and senarating the forme. A KOOP Zaznam vnutro 3.11.2009 14:38 Stránka 6 How to use the „Motor vehicle accident report“ form The „Motor vehicle accident report“ form is in full compliance with the model made by Comité Européen des Assurances (CEA). It is designed to be applied in case of any motor vehicle accidents, it serves to report the state of facts and no agreement on guilt is necessary for its fulfilment. It can also include contrary statements, on a separate sheet of paper if neede. It the other participant of the accident has the same form agreed by Comité Européen des Assurances, but in a different language, these forms are equal. Therefore you may translate its contents point by point on the basis of your own form. This is the reason why the individual points are numbered. On the place of the accident 1. Use only one set of forms for 2 participated vehicles (two sets for 3 participated vehicles, etc.). It is not important who delivers and fills in the form. Use a ball pen and write so that the copies are readable. 2. When filling in the „Motor vehicle accident report “ be aware of the following: – questions in point 8 refer to your insurance documents (number of the liability insurance document, green card), – questions in point 9 refer to your driving licence, – mark precisely the crash point (point 10), – mark with a cross the variant (1 – 17) related to your motor vehicle accident (point 12) and define the number of marked spaces in the end, – make a drawing of the accident (point 13). 3. Do not forget to mention all possible witnesses of the accident, their names and addresses, especially if your opinion is different from the opinions of other participants of the accident. 4. Sign the „Motor vehicle accident report“ and have it signed by the other driver, too. Give one copy to the other participant of the accident and keep your copy in order to give it to your insurer. After you have filled in the form – when communicating the accident to the insurance company, do not forget to state when and where the vehicle could be checked by an expert, – under no circumstances modify the data in the foreside of the form, – deliver the form immediately to the insurance company. 8-280-09 4/5 The „Motor vehicle accident report“ form should be kept on hand. Keep it in the vehicle, please.