Car Accident Form


Accident Declaration

This declaration should be completed and sent to the company within 48 hours from the date of accident. Sending this declaration do not implicate the company in any responsability.

IMPORTANT: The insured and any other person should not admit any resposibility without refering to the company.

Name of the Insured
    
Policy No.
    
(Example: MTP/666777)
Address
    
Email
    
Car Model
    
Registration Number
    
Name of the driver
at the time of accident
    
Age of the driver
at the time of accident
    
Address
    
Driving Permit No.
   
Date of Issuance
   
Place of Accident
    
Name of City and Street
    
Did any Official Authority
Investigate the Accident?
        
Date and Time of Accident
    
Please describe clearly how
the accident happened
    
Name and Addresses
of Witnesses
  
Name    Address
  
  
  
Names and Addresses
of persons that were
in the car during accident
  
Name    Address
  
  
  
  
Did the police write
a report?
         
Did an expert examine
the accident?
         
Name of the expert
    
Damages of the insured car:
    
 
In case of Bodily Injury:
  
Injured Person's Name
  
Address
  
Telephone Number
  
Hospital transferred to
  
 
Information related to Third Party 1
  
Car owner's name
 
Car owner's address
 
Driver's name
 
Driver's address
 
Car model
  
Registration No.
  
 
Information related to Third Party 2
  
Car owner's name
 
Car owner's address
 
Driver's name
 
Driver's address
 
Car model
  
Registration No.
  
 
Information related to Third Party 3
  
Car owner's name
 
Car owner's address
 
Driver's name
 
Driver's address
 
Car model
  
Registration No.
  
 
Damages of the Third Party
  

I declare that I have answered all above questions as to the best of my knowledge and I pledge to provide AROPE Insurance s.a.l. all possible assistance in relation to this accident. I also declare that I do not hold any other insurance policy that will allow me to submit any claim in relation to this accident.