Fill and Sign the Tennessee Lineal Transfer Form

GAUNTLET MOTOR ACCIIDENT REPORT FORM GAUNTLET MOTOR ACC DENT REPORT FORM Gauntlet Risk Management Ltd Crown House Armley Road LEEDS LS12 2EJ Tel. 0113 244 8686 - Fax. 0113 2438668 - E-mail. claims@gauntletgroup.com Please complete this form fully on both sides and continue on a separate sheet of paper if necessary. It is a condition of your policy to report all incidents as soon as possible even if you do not intend to make a claim. Any correspondence received in connection with the incident must be submitted immediately Policyholder Address Policy Number Name of Depot Post Code Telephone No. Fax No. Occupation / Business E-mail address Are you registered with HM Customs & Excise as taxable vat? YES If partially exempt what % can you reclaim? Driver or person last in charge if unattended Name Occupation Agency Driver Address State Class of Licence held (Car, PCV, HGV etc) YES/NO Date of Birth Date of passing driving test for vehicle involved in accident Licence Number Groups Expiry Date Give details of all motoring convictions or prosecutions pending (I.e. charge: date: penalty). If none state "None" Give details of all accidents or losses in the last three years. If none state None Give details of any physical defect, infirmity, defective vision or hearing Vehicle Make/Model Year of make Reg No. Type of body and no. of seats Gross vehicle weight (GVW) For what purpose was the vehicle being used? If goods were being carried for business purposes please state below the nature of the load and the name and address of the owners of the load How many passengers were being carried? Damage to the Insured Vehicle Full details of damage If your vehicle is damaged do you wish to claim on your policy if the vehicle is covered Is the vehicle still in use (I.e. mobile and road-worth)? YES/NO YES / NO Estimated Cost of Repairs When and where can the vehicle be examined? (please provide a phone number if possible) Please note that if damage to your vehicle is covered under the policy and the vehicle is considered beyond economic repair it may be moved to free and safe storage to avoid unnecessary storage charges Description of Accident Date of Incident Time of Incident AM / PM Place of Incident Speed of Vehicles Yours: Width of Road MPH Conditions What lights was your vehicle displaying? Did the police take details of the incident? Others: What lights was the other vehicle/s displaying? Station YES/NO Was anybody cautioned? If “Yes” please give details Copyright Gauntlet Group 2007 Speed Limit Street lights on? YES/NO If “Yes” please give details below Officers name and number Did you make a written statement? MPH Weather/Visibility Page 1 of 2 YES/NO MPH YES/NO Please confirm exactly how the incident happened and confirm details of all property damage. If necessary please also provide a sketch of the incident to include the width of the roads, type and position of all road signs & markings, direction of travel of all parties and the points of impact(s) Written Description: Sketch: If necessary, please continue on a separate piece of paper If necessary, please continue on a separate piece of paper Who do you blame for the incident and why? Witnesses Please confirm the names, addresses and telephone numbers of all passengers in your vehicle Please confirm the names, addresses and telephone numbers of all independent witnesses to the incident Other parties involved. Please confirm the names, addresses and tel. no’s of all other parties involved (continue on a separate sheet if necessary) Name & address of owner / driver Telephone number Vehicle make / model / registration no. Vehicle colour Damage / point of impact Number of occupants Name, address, policy no. of Insurers Name & address of injured persons Were any injured parties vehicle drivers, passengers or pedestrians? Were seat belts fitted to all vehicles? Yes / No If “Yes” were they in use at the time of the incident? Yes / No Please confirm details of all apparent injuries Taken to hospital? Yes / No Name of hospital attended? Detained? Yes / No Property Damage: Name & address of owners & extent of damage Notice & Declaration (please read carefully) Notice: Insurers pass information to the Claims and Underwriting Exchange Register (CUE), run by Insurance Database Services Ltd (IDSL) and the Motor Insurance Anti-Fraud and Theft Register (MIAFTR), run by the Association of British Insurers (ABI). They also exchange information with other Insurers and other organisations through various other databases. The aim is to help them check information provided and also to prevent fraudulent claims. Under the conditions of your policy, you must tell us about any incident (such as an accident or theft) which may or may not give rise to a claim. Your insurers will pass information relating to this incident to the registers. In addition your policy details will be added to the Motor Insurance Database (MID), run by the Motor Insurers’ Information Centre (MIIC). MID data may be used by the DVLA and DVLNI for the purpose of Electronic Vehicle Licensing and by the police for the purpose of establishing whether a driver’s use of the vehicle is likely to be covered by a motor insurance policy and/or for preventing and detecting crime. If you are involved in an accident (in the UK or abroad), other UK Insurers, the Motor Insurers’ Bureau (MIB) and MIIC may search the MID to obtain relevant policy information. Persons pursuing a claim in respect of a road traffic accident (including citizens of other countries) may also obtain relevant information which is held on the MID. You can find out more about this from us, or at www.miic.org.uk. Your information may also be disclosed to agents and service providers appointed by your insurers (such as claims handling agents, approved engineers, and investigative agents) and may be transferred to any country including countries outside the European Economic Area for the purposes of administration. Your information may also be shared with others with organisations associated with your insurers. Declaration: I/We hereby declare that the above information and statements are true to the best of my/our knowledge and belief. I/We understand that you may ask for information from other Insurers to check the answers I/We have provided. No other insurance is in force and I/We will render every assistance required by my/our insurers. Policyholder’s or Company Official’s Signature Copyright Gauntlet Group 2007 Date Page 2 of 2