Accident report

Select one of these three options:

Friendly declaration of accident

ALL FIELDS MARKED WITH * ARE REQUIRED

TAX ID

Phone

E-mail address

1. DATE OF ACCIDENT

Accident time

2. LOCATION (town, street, road, etc...)

3. VICTIMS

4. PROPERTY DAMAGE

Vehicles other than A and B

Yes No

Objects other than the vehicle

Yes No

5. WITNESSES: Name, address and telephone number. Specify if they are A or B occupants

VEHICLE A (OWN)

6. INSURED (See Insurance Policy)

Name

Surname

Address

CP

Country

7. VEHICLE

Make, model

Registration

8. INSURANCE

Name

Policy No.

Green Card No.

Valid until

Covers own damages

9. DRIVER (see driver's license)

Name and surname

Address

Driving license No.

Category (A, B,...)

Issued

a

11. DAMAGE ASSESSED

12. CIRCUMSTANCES. INDICATE "YES" IN EACH BOX AS APPROPRIATE

I was parked/stopped

Yes No

Coming out of a parking lot/ opening door

Yes No

I was going to park

Yes No

It came out of a parking lot, a private place, a dirt road.

Yes No

I was entering a parking lot, a private place, a dirt road.

Yes No

Entered a rotating direction square

Yes No

I was driving in a square in a rotating direction.

Yes No

Rear-end collision with the other vehicle traveling in the same direction and in the same lane.

Yes No

He was driving in the same direction and in a different lane.

Yes No

Changing lanes

Yes No

Forward

Yes No

Turned right

Yes No

Turned left

Yes No

Reversed

Yes No

Invaded the area reserved for traffic in the opposite direction

Yes No

Coming from the right (at a crossroads)

Yes No

Failure to obey a red light or red traffic signal

Yes No

VEHICLE B (OPPOSITE)

6. INSURED (See Insurance Policy)

Name

Surname

Address

CP

Country

7. VEHICLE

Make, model

Registration

8. INSURANCE

Name

Policy No.

Green Card No.

Valid until

Covers own damages

9. DRIVER (see driver's license)

Name and surname

Address

Driving license No.

Category (A, B,...)

Issued

a

11. DAMAGE ASSESSED

12. CIRCUMSTANCES. INDICATE "YES" IN EACH BOX AS APPROPRIATE

I was parked/stopped

Yes No

Coming out of a parking lot/ opening door

Yes No

I was going to park

Yes No

It came out of a parking lot, a private place, a dirt road.

Yes No

I was entering a parking lot, a private place, a dirt road.

Yes No

Entering a rotating direction square

Yes No

I was driving in a square in a rotating direction.

Yes No

Rear-end collision with another vehicle traveling in the same direction and in the same lane.

Yes No

He was driving in the same direction and in a different lane.

Yes No

Changing lanes

Yes No

Forward

Yes No

Turned right

Yes No

Turned left

Yes No

Reversed

Yes No

Invaded the part reserved for traffic in the opposite direction

Yes No

Coming from the right (at a crossroads)

Yes No

Failure to obey a red light or red traffic signal

Yes No

SEND

Is it signed by both of you?

Yes No

Comments to the brokerage

Data protection

I have read and accept the Privacy Policy

life

Health

Home

Funeral

Car

Trade/company

Communities

Others

Accident report

Friendly declaration of accident

VEHICLE A (OWN)

VEHICLE B (OPPOSITE)

SEND