Schedule 1

Forms

Current

FORM 1

Regulation 7

STATEMENT OF EARNINGS BY A LOSS OF EARNING CAPACITY BENEFICIARY

Name of claimant

Address

Claim no.

Statement period

Earnings received as an employee

Start date Finish date Name and address Weekly hours Gross pay of employer

Other earnings

Start date Finish date Nature of activity Gross earnings

DECLARATION

I declare that the information on this form is true and correct to the best of my knowledge and belief.

Signed

Date of signing

FORM 2

Regulation 8(1)

DRIVER'S ACCIDENT REPORT

1 Details of driver

Surname
Given names
Mr, Mrs, Ms
Home address
Home telephone number
Work telephone number
Mobile telephone number
Date of birth
Driver's licence number
Expiry date
State of issue
Period held

2 Accident details

Date of accident
Day of the week
Time
Was the driver injured?

Yes

Location of the accident
Describe the circumstances of the accident
Draw a diagram of the accident scene, showing the position of all vehicles and any persons injured

3 Details of driver's vehicle

Registration number of the vehicle driven at the time of the accident
State of registration
Vehicle type (car, truck, motor cycle)
Name and address of owner—if not the driver
What was the estimated speed at time of impact
Mark the points of impact on the diagram with an X

Estimate cost of repairs
Level of damage—

Level 1—minor damage, cosmetic panel damage

Level 2—moderate damage, driveable vehicle

Level 3—major damage—car towed

Level 4—extensive damage—car likely to be unrepairable

If your vehicle was towed—

Name and address of firm or persons who towed vehicle away

Name of panel beater
Name of comprehensive insurer

4 Details of witnesses

Surname
Given names
Home address
Home telephone number
Work telephone number
Mobile telephone number

5 Details of other occupants in driver's vehicle

Show by number, the position in the vehicle for other occupants on the diagram
Position number
Surname
Given names
Home address
Home telephone number
Work telephone number
Mobile telephone number
Was this person injured?

Yes

6 Details of all other vehicles involved in the accident

Surname
Given names
Home address
Registration number
Number of persons in vehicle
Level of damage (see question 3 for levels 1 to 4)

7 Details of all other persons involved in the accident (not in a vehicle at the time of the accident)

Surname
Given names
Home address
Type of road user (e.g. pedestrian, cyclist etc.)
Was this person injured?

Yes

Declaration by person making this report

I hereby declare that the above information is true and correct to the best of my knowledge and belief.

Signature

Date

FORM 3

Regulation 8(2)

Transport Authority Accident Report

1 Name of Authority

Returned to

2 Details of Transport Authority/Operator involved

Vehicle types
End
Vehicle Identification Numbers
Destinations
Time table

3 Authority/Operator driver details

Surname
Given names
Employee identification number
Male/Female

4 Accident details

Date of accident
Day of the week
Time a.m./p.m.
Location of the accident
Description of the accident
Visibility good/bad
Weather wet/dry
Lighting on/off
Draw a diagram of the accident showing the position of all vehicles and any injured person as at time of impact
Name of the MTA officer or loss assessor if attended at the scene

5 Police details

Did the police attend the accident scene—

Yes

If yes please provide the following details—

Name of the police officer who attended at the scene

Police officer's badge number

Station where officer located

6 Details of persons injured in Authority/Operator Vehicle

Surname
Given names
Residential address
Home telephone number
Work telephone number
Mobile telephone number
Male/Female
Age
Apparent injuries sustained
Taken to hospital by ambulance—

Yes

If yes, name of hospital

7 Details of other injured persons

Surname
Given names
Residential address
Home telephone number
Work telephone number
Mobile telephone number
Male/Female
Age
Registration number if in a vehicle
Type of road user
Apparent injuries sustained
Taken to hospital by ambulance—

Yes

If yes, name of hospital

8 Details of all other vehicles involved in the accident

Surname
Given names
Residential address
Home telephone number
Work telephone number
Mobile telephone number
Registration number
State of registration
Make and colour of vehicle
Number of passengers in vehicle, excluding the driver—

Males

Females

Children

How did the vehicle leave the scene
Description of damage sustained by vehicle

9 Details of witnesses

Surname
Given names
Residential address
Home telephone number
Work telephone number
Mobile telephone number
Did an authority employee witness the accident?

Yes

10 General remarks

Have you any doubt the injury occurred as stated?

If so why?

Completed by

Name

Position

Signature

Date

If report is from tourist railway/tram operator

Name of operator
Address
Telephone number

FORM 4

Regulation 9

CONTRACT OF INSURANCE

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