Type of cover (please tick) : Comprehensive Type of claim (please tick) : Accident

Third party fire & theft Theft/attempted theft

Third party only Windscreen

Motor Incident Report Form

1.Policyholder details

M

otor Claims

Name:

Address:

Mobile:

Email address:

Are you registered for VAT? Yes No If ‘Yes’, state registered number:

2.Vehicle details

Registration Number:

Make:

Model:

Horse power/cubic capacity (H.P./C.C.):

Year of manufacture:

Was there a trailer attached at the time of the accident?

Yes No

If ‘No’, give details:

Does any financial institution or hire purchase company have an interest in the vehicle?

Yes No

If ‘Yes’, give name and address:

1

. This form should be completed by the policyholder.

2. In the event of an accident please complete all sections except section 8.

3. In the event of a theft please complete sections 1, 2, 3, 8, 9 and 11 only.

4. In the event of a theft please get An Garda Siochána to complete 8b.

admission of liability on the part of the company and that all claims are subject to policy terms and conditions.

Claim Number

BEFORE COMPLETING THIS FORM, PLEASE SEE INSTRUCTIONS BELOW. PLEASE USE BLOCK CAPITALS.

Insured: Third party:

Insured: Third party:

4.Accident details

Location:

Date:

Name of station and Garda/Police Officer to whom the accident was reported?

Were alcohol/drugs in any way a contributing factor to the accident?

If ‘Yes’, give details:

Was the driver’s view obstructed in any way?

If ‘Yes’, give details:

How far away was the other party when first seen by the driver?

What signals were given?

3.Person driving (In the event of theft give details of the person last in charge of the vehicle)

Name:

Address:

Date of birth:

Occupation:

Licence Number:

Type of Licence: Full Provisional

Date first issued (if Provisional):

Date test passed (if Full):

Licence operative from:

State relationship of the driver to the policyholder (family, employee, etc.):

Does the driver suffer from any physical or mental disabilities? Yes No

If ‘Yes’ please give details:

Has the driver ever been:

(i) Refused motor insurance, renewal, or had special terms imposed? Yes No

(ii) Convicted of a motor offence? Yes No

(iii) Involved in a previous motor accident? Yes No

If ‘Yes’, to (i), (ii) or (iii) above, please give details:

km/hr

8a.Theft details

Date vehicle left unattended:

Time vehicle left unattended:

Date loss discovered:

Time loss discovered:

Mileage at time of loss:

Date vehicle purchased:

Purchase price:

Your estimate of current value:

How was the vehicle secured prior to the theft?

Name of station and Garda/Police Officer to whom theft was reported:

Detail any marks, damage or other special features which would help establish the identity of the vehicle:

Detail any property stolen from the vehicle, including age and value:

List any major parts which have been renewed in the last 12 months (attach invoices where possible):

Were they driver/passenger/

pedestrian/cyclist etc.?

In which vehicle?

Was a seat belt in use? Yes No

Yes No

Yes No

1. 2. 3.

7.Witness(es) details

Name:

Address:

Were they passenger/

5.Other vehicle(s) or property involved

Registration Number:

Extent of damage:

Insurance company:

Policy Number:

1. 2. 3.

1. 2. 3.

9.Circumstances of accident

Please describe in detail exactly how loss/damage/theft occurred.

Information Used: logging of any new claim notifications and any claim settlement for damage and injury.

Purpose: to confirm your personal data and verify claims information and/or for prevention and detection of crime and fraud through the Claims

and Underwriting Exchange Database and Insurance Link Anti-Fraud register.

Processing is necessary: to comply with legal obligations.

Information Used: vehicle registration number.

Purpose: to identify whether a vehicle has been taxed, NCT or if the vehicle has been involved in a claim or written off using the VRN system. The

Motor Insurance Database managed by the Motor Insurers’ Bureau ("MIB"), MID data is used by the DVA for the purpose of Electronic Vehicle

Licensing and by the Police Service for Northern Ireland (PSNI) for the purposes 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 and the MIB may search the MID to obtain relevant policy information. Persons pursuing a claim in respect of a road traffic accident

Information Used: Personal Public Service (PPS) Number

Purpose: If you make a claim for personal injuries against an Allianz customer, we are obliged to provide the Department of Employment Affairs

and Social Protection with your PPS Number to comply with the Recovery of Benefits and Assistance (RBA) Scheme.

Processing is necessary: to comply with legal obligations.

We may share your personal information with: the Allianz Group, our agents, third parties who provide services to us (engineers, repairers, motor

assessors, loss adjustors, expert appraisers, expert witnesses, private investigators, claims handling agents etc.), your intermediary and other

insurers (either directly or via those acting for the insurer such as loss adjusters or investigators or solicitors); providers of essential services (e.g.

telecommunications, postal/courier providers, IT service providers, software providers, payment processor); other third parties involved in

administering your claim; regulatory bodies and law enforcement bodies, including the Garda and PSNI (for example, where we are required to do

policyholder, we will share your information with our policyholder (e.g. employer/sport club) and or their agent including the financial outcome of

your claim.

The personal information you provide may be used by us and shared with other insurers as well as certain statutory and other authorised bodies for

anti-fraud purposes: other insurance companies to deal with the claim and to safeguard against non-disclosure and help prevent fraudulent claims;

ROI- the Insurance Link Anti-Fraud register (for more info see www.inslink.ie) to prevent and detect fraud; No Claim Discount (NCD) to combat fraud;

the Motor Insurers’ Bureau of Ireland (MIBI) to assist in preventing or detecting theft and fraud and to pay claims; private investigators, tracing

t

he insurance industry and publicly available information to detect or prevent possible criminal activity or fraud. NI- ; the Motor Insurance Anti Fraud

and Theft Register (MIAFTR) and the Insurance Fraud Bureau, Claims and Underwriting Exchange Register (CUE) which are run by the MIB, to

prevent and detect fraud; the Motor Insurers’ Bureau (MIB) to assist in preventing or detecting theft and fraud and to pay claims; private

insurers and the MIB 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 MID. You can find out more on www.mib.org.uk

We will use your personal information to detect and prevent fraudulent practices and fight financial crime to meet our regulatory responsibilities.

Where we obtain data from the above sources, the categories we obtain will be claims information relating to claims handling and fraud

prevention. We may need your consent for the processing of certain data and in these cases, we will inform you of such processing and the reason

for this at the time consent is captured.

Protecting Information Outside the European Economic Area

Your personal data may be transferred to and/or accessed from a country outside the European Economic Area (“EEA”). We will always take

steps to ensure that any transfer of information outside the EEA is carefully managed to protect your privacy rights. Such transfer/access within

the Allianz Group will be covered on the basis of the Allianz Group binding corporate rules (BCRs) known as the Allianz Privacy Standard (APS)

information is disclosed.

Representation

If you provide information about someone else, such as an additional insured, we will endeavour to provide this Data Protection Statement to them.

Where it is not possible to do so, you must make them aware of this Data Protection Statement and the terms of the insurance (including changes to

the terms or processing activities) and encourage them to read this Data Protection Statement to find out more.

How long we keep your personal information

We will keep your personal data only for as long as it is required for your insurance contract, to handle claims and to comply with our legal and

regulatory obligations as documented in our Records Management Policy. For the majority of policy data, this is seven years after the end of that

transaction. If you do not accept a quote or complete an application for an insurance policy, your data will be kept for fifteen months and processed

in line with this Statement. When a potential claim or actual claim is taken out on a policy, we hold details around this claim until a full and final

withdrawing consent and requests for restriction/erasure may affect our ability to provide you with a contract of insurance. Some of the above

rights are subject to limitations in order for us to comply with a number of legal and regulatory obligations. You have the right to data portability for

insurance purposes (contact dataprotectionoffi[email protected]). You also have the right to lodge a complaint with the Data Protection

Commissioner. For further information, please see the section “Contacting Us” below.

Automated decision making

As part of the claim handling, Allianz may use automated decision-making. If you are making a claim, we may use profiling and other forms of

automated processing to assess if your claim may be fraudulent and we may use your sensitive information, to carry out this assessment. For

example, we may use your unspent motoring convictions for motoring insurance. We use automated decision making as it is necessary for entering

into, or performance of your insurance policy between you as the data subject and Allianz as data controller, and other uses such as those

authorised by law.

11. Declaration

I/WE HEREBY CERTIFY that to the best of my/our knowledge and belief the statements and particulars contained herein are fully made and

that I/we have withheld no material fact concerning the accident or the injured party.

Signature of Policyholder

Date

7

01 CL 08.20 KD

P

Elmpark, Merrion Road, Dublin 4, D04 Y6Y6, Ireland.

Dublin 2, D02 RD28

Locall Number: 1890 252 231

Email: [email protected]

Fax: +353 57 868 4757

available at www.allianz.ie and will take effect on the date that it is updated.

Please review this Data Protection Statement periodically to ensure you remain informed.