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[Logo insurance company]

Annex 2 You have been injured in an accident

GENERAL INFORMATION

Claim-file reference (as detailed in accompanying letter): ……….………. Date, location and time of accident:……….………

1. Personal details

First name(s), last name: ……… Date of birth: ………..……… Address: ……… Telephone (home): ………Telephone (mobile): ……… E-mail address: ……… Bank account no.: ……….……… Marital status: Single – Married – Cohabiting – Widow/Widower – Separated – Divorced

Name of spouse/cohabiting partner: ……… Date of birth of spouse/cohabiting partner: ………/………/………

Working status of spouse/cohabiting partner: □ Full time

□ Part time: ……… hours/week Household composition:

First name, last

name Date of birth Dependent Cohabiting

Spouse/partner □ Yes □ No □ Yes □ No

Child(ren) □ Yes □ No □ Yes □ No

□ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No

Parent(s) □ Yes □ No □ Yes □ No

□ Yes □ No □ Yes □ No Is/are the perpetrator(s) of the accident a relation of any kind or a dependent? □ Yes □ No If yes, please give details:

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2. Working status

Have you suffered a loss of income as a result of the accident? □ Yes □ No

If yes, please provide evidence of your income for the month prior to the accident (e.g. a payslip) Working status as at date of

accident Tick as appropriate Since Worker (blue-collar) □ Employee (white-collar) □ Civil servant/military officer

- statutory - contracted □ □ Self-employed □ Student/Child □ Retired □ Early retired □ Jobseeker □

In receipt of benefit from mutual health-insurance provider

□ In receipt of benefit from

CPAS/OCMW

Unemployed □

Other □

• If you are in paid employment

Name and address of your employer: ………. Contract Full-time Part-time

No. of hours/week

Wage/salary Gross Taxable Net Per hour

Per month Per year

Other benefits (bonuses, 13th month, meal vouchers, etc.): ……….. ……….

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If you are self-employed: □ as main occupation □ as secondary occupation

Tick as appropriate Taxable income Fixed costs (total)

Company director □

One-person company □

Independent worker □

Please enclose tax assessment notices for the past three years. BCE/KBO no.: ………..

• If you are a student:

Name of school/college: ……….……….……… Type and duration of course:………. Year of course at time of accident: ………….………

3. Circumstances of the accident

Was the incident: □ an accident at work or on the way to work?

□ an accident at school/college or on the way to school/college? □ a private accident?

• If an accident at work or on the way to work:

Name and address of your employer's occupational-accident insurer:……… ………. ………. ………. • If an accident at school/college or on the way to school/college:

Address of school/college and name and address of school's/college's insurer:

……… ………. ………. ………. Were there any witnesses to the accident? □ Yes □ No

If yes, please give details (first name, last name and address):

……… ……… ……….

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4. Material consequences of the accident

Description of damage to items other than a vehicle. Please enclose all receipts/invoices/other evidence and retain any damaged items.

Item Description of damage Date of purchase Amount paid for item (Estimate)

5. Bodily injury caused by the accident

Nature of injuries: ……….. ……… ………. ………. Were you admitted to hospital following the accident? □ Yes □ No

Name of treating doctor and/or clinic: ………. ………. If admitted to hospital: Date of admission: ………/………/……… Date of discharge: ………/………/……… Have you been completely unable to work? □ Yes □ No

If yes, from ………/………/……… to ………/………/……… Are you still receiving treatment? □ Yes □ No

Are you completely recovered? □ Yes □ No If yes, since ………/………/……… Please enclose the document “Medical Certificate to be completed by your doctor”.

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6. Involvement of associations or insurers

Following the accident, did you approach any of the associations/insurers listed below? If yes, please give details in the table.

Details of association/insurer Reference Occupational-accident insurer Medical-expenses insurer Hospitalisation insurer Personal-accident insurer Income-protection insurer Material-damage insurer Travel insurer Mutual health-insurance provider (mutualité/mutualiteit)

Public Social Assistance Centre (CPAS/OCMW)

Other

Mutual health-insurance provider (attach a sticker):

Do you hold personal/family civil-liability cover? □ Yes □ No Do you hold legal-expenses cover? □ Yes □ No

7. Comments

……… ……… ………

This questionnaire is not exhaustive. Please forward all other information you consider to be relevant or necessary in respect of your accident.

The personal data collected by means of this document is used for the following purposes: managing the claim in question, particularly in terms of recording and assessing the bodily injury sustained by the undersigned or by the person s/he represents; detecting and preventing fraud; and processing for statistical purposes.

For these purposes alone, this data may be passed on, if necessary, to other insurance companies concerned by compensation for the bodily injury sustained by the undersigned or of the person s/he represents, to these companies' representative in Belgium, their correspondent abroad, their reinsurers, their claims settlement office, an expert, a lawyer, a technical advisory body, the insurance agent of the undersigned or of the person s/he represents, and more generally, to any

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person or entity filing an action or against whom an action is filed in connection with the bodily injury mentioned above.

The undersigned hereby consents to the use of data on his/her health or that of the person s/he represents when this data is required for management of the claim in question. The undersigned consents to data on his/her health or that of the person s/he represents being used without a healthcare professional being responsible for that use. The undersigned consents to a medical examination, if one is required.

Such health-related data is handled with the utmost discretion, and only by authorized people. Those concerned may consult their own data and, if necessary, have it corrected by sending a signed, dated request, along with a copy of both sides of their identity card, to the insurer who requested the information. Further information may be obtained from the same insurer.

Within the framework of the compensation procedure, the insurer has to comply with « the rules of conduct for claim settlement: contact with victims of serious accidents » which can be found on www.assuralia.be. Any complaint about the insurance company's failure to respect the code of conduct must be addressed by the consumer to the complaints department of the company concerned, in accordance with the rules of conduct for complaints management in the insurance companies (available on www.assuralia.be). If the consumer considers the answer given by this department to be unsatisfactory, he can lodge the complaint with the Insurance Ombudsman through www.ombudsman.as.

Done at ...……….. Date: … / …. / ……….

Name and first name(s) of signatory:……….……… Address: ………. Capacity:……… Telephone (home):……… Telephone (mobile): ……… E-mail address: ………

Signature 1

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