The Tatil Group TRINIDAD AND TOBAGO INSURANCE LIMITED

TATIL LIFE ASSURANCE LIMITED 11 Maraval Road, Port of Spain, Trinidad and Tobago, W.I. P.O. Box 1004

Tel: (868) 628-2845 or (868) 622-5351-8 Fax: (868) 628-6545 or (868) 628-0035

MOTOR VEHICLE ACCIDENT REPORT FORM Please give complete answers to all questions

FOR OFFICIAL USE ONLY

Producer NameBranchClaim NumberAdjuster Name

TTHHEE IINNSSUURREEDD Name: Email Address: Postal Address: Telephone: Employer: Telephone:

Occupation: Are you VAT registered? State VAT Registration Number:

TTHHEE PPOOLLIICCYY Policy Number: Effective Date: Expiry Date: Type of Coverage Comprehensive ٱ Fire & Theft ٱ

Third Party ٱ Crash Cash ٱ If not Tatil, with Courtesy Cash ٱ whom is it insured?

Registration No. Make and Model of Vehicle Year Chassis No. & Engine No. Sum Insured

Is the vehicle registered in your name? If NO, in whose name? Is the vehicle subject to any finance agreement? If YES, give details?

TTHHEE DDRRIIVVEERR Name: Sex: Postal Address: Telephone:

Business Address: Telephone:

Occupation: Employer:

Date of Birth Age Permit Number Class Date of Issue Date of Expiry

Has Driver been previously involved in an accident? If YES, give details. Has Driver ever been charged with a Traffic Offence? If YES, give details. Driver’s relation to the Insured. If employee, how long employed? Does Driver own a Motor Car? Registration Number:

Where is it insured? Policy/Certificate Number:

THE ACCIDENT/THEFT Date: Time: am/pm Place:For what purpose was the vehicle being used? Please describe fully. Direction of Travel Direction of Travel Insured’s Vehicle: Third Party’s Vehicle: Speed at time of accident: Condition of Road:

Was horn sounded? Was visibility good? Police Station reported to: Name and Number Date and Time reported: of Police Officer:

THE THIRD PARTY Vehicle Registration Number: Make & Model of Vehicle: Colour of Vehicle: Owner’s Name: Owner’s Address: Driver’s Name: Driver’s Address: Insurance Company: Policy & Certificate Number: Description of Damages and Your Estimate of the Cost of Repairs:

DAMAGES TO INSURED’S VEHICLE DAMAGES TO INSURED’S VEHICLE

Description of Damages: Description of Damages:

Name of Repairer: Was Estimate Prepared? Cost: Where can the vehicle be inspected?

PASSENGERS IN YOUR VEHICLE Name Age Address Details of Injury Sustained (if any) Physician or Hospital

PASSENGERS IN OTHER VEHICLE/PEDESTRIANS Name Age Address Details of Injury Sustained (if any) Physician or Hospital

INDEPENDENT WITNESSES

Name Address Telephone

DRAW SKETCH OF ACCIDENT

In your opinion who was at fault? Did such person admit responsibility?

I/WE DECLARE THAT THE ABOVE STATEMENTS AND FACTS ARE TRUE AND THAT I/WE HAVE NOT WITHHELD ANY INFORMATION WITHIN MY/OUR KNOWLEDGE CONNECTED WITH THE CLAIM.

SIGNATURE OF INSURED:

SIGNATURE OF DRIVER:

DATE:

DATE:

THE COMPANY DOES NOT ADMIT ANY LIABILITY BY THE USE OF THIS FORM

GIVE FULL DETAILS OF ACCIDENT

DeclarationPlease confirm by selecting this box your declaration as follows:

Website Address: http://www.tatil.co.tt or Email: motorclaims@tatil.co.tt

THE INSUREDOccupation:

THE POLICYType of CoverageComprehensive ٱRegistration No.Make and Model of VehicleYear

Chassis No. & Engine No.Sum InsuredIs the vehicle registered in yourIs the vehicle subject to any financeDate of BirthAge

Permit NumberClassDate of IssueDate of ExpiryHas Driver ever been charged with aIf employee, how long employed?Does Driver own a Motor Car? Where is it insured? Date:

For what purpose was the vehiclePolice Station reported to: Vehicle Registration Number:Description of Damages andWhere can the vehicle be inspected?

PASSENGERS IN YOUR VEHICLEName

AgeAddressDetails of Injury Sustained (if any)Physician or HospitalPASSENGERS IN OTHER VEHICLE/PEDESTRIANSName

AgeAddressDetails of Injury Sustained (if any)Physician or HospitalINDEPENDENT WITNESSESName

AddressTelephoneGIVE FULL DETAILS OF ACCIDENTSIGNATURE OF INSURED: ___________________________________SIGNATURE OF DRIVER: __________________________________THE COMPANY DOES NOT ADMIT ANY LIABILITY BY THE USE OF THIS

155_af_date: 152_af_date: 150: OffText1: 149: 148: 147: 146: 145: 144: 143: 142: 141: 140: 139: 138: 137: 136: 135: 134: 133: 132: 131: 130: 129: 128: 127: 126: 125: 124: 123: 122: 121: 120: 119: 118: 117: 116: 115: 114: 113: 112: 111: 110: 109: 108: 107: 106: 105: 104: 103: 102: 101: 99: 98: 97: 96: 95: 94: 93: 92: 91: 90: 89: 88: 87: 86: 85: 84: 83: 82: 81: 80: 79: 78: 77: 76: 75: 74: 73: 72: 71: 70: 69: 68: 67: 66: 65: 64: 63: 62: 61: 60: 59: 58: 57: 56: 55: 54: 53: 52: 51: 50: 49_af_date: 48: 47: 46: 45: 44: 43: 42: 39: 38: 37: 41_af_date: 40_af_date: 36_af_date: 35: 34: 33: 32: 31: 30: 29: 28: 27: 26: 25: 24: 23: 22: 21: 20: 15_af_date: 14_af_date: 13: 12: 11: 10: 9: 8: 7: 6: 5: 4: 3: 2: 1: 16a: Off16b: Off16c: Off19: 17: Off18: Off