European Accident Statement Form
European accident statement form is a facility for European masses to claim accidental losses and compensations. The objective of this form is concerned with the claimant and with the responsible insurance company.
Sample European Accident Statement Form:
For Personal Use:
Name of the claimant: ____________
Valid contact number: _____________
Address (City/ State/ ZIP): _______________________
E- mail id: ________
Date of Birth (DD/ MM/ YY): _____________________________________
Official Details:
Date of Driving Test Passed: _______________________
Occupation: ______________________
Date of Insurance: _________________
Mention the Make/ Model & Type of vehicle: ____________________
Date of Vehicle registration: _______________
Registration Remarks (if any): ______________
Did you get injured?
- Yes
- No
Nature of Damage: ______________________
Give the details of types of injury and any kind of impairment is there?
_________________________________________
Is the vehicle still in use?
________________________________________
Status of Offence: ________________________
Name & Address of the insurance company:
________________________________________________________
Provide full details of driver driving convictions including pending prosecutions:
____________________________________________________________________
| Date | Offence | Penalties |
Did you register an FIR?
- Yes
- No
Declaration:
I/ We declare that above mentioned particulars are true to the best of my knowledge:
Signature:
Category: Statement Forms
