Relationship to You: Description of Property Damage: Nature & Extent of Damage: Yes No Do you own the property? If no, please advise owner: Property Yes No Do you occupy the property? If no, please advise tenant: What type of property caused the accident? Yes No Did the property contain any defect? If yes, please describe: Plant or Describe the plant or equipment and its uses : Equipment Type of Vehicle: Registration Number: Drivers Name: Motor Vehicle Drivers Address: Owners Name: Owners Address: Type of Animal: Yes No Do you own the animal? Animal Please describe how the animal escaped and caused the injury: Attendance | Treatment at the Scene Was Treatment given at the scene? If “Yes”, by whom? Yes No Describe extent of any injuries: Was Ambulance, Fire or Police called Yes No If so, please advise Station & Officer in attendance: Were any charges laid or charges pending in Yes No respect to this incident? Is so, please advise details: Other Insurance Are you claiming insurance or compensation from any other insurance company? e.g. Yes No Workers Compensation, Traffic Accident Commission, CTP?
Relationship to You: Property Description of Property Damage: Nature & Extent of Damage: Do you own the property? Yes No If no, please advise owner: Do you occupy the property? Yes No If no, please advise tenant: What type of property caused the accident? Did the property contain any defect? Yes No If yes, please describe: Plant or Equipment Describe the plant or equipment and its uses : Motor Vehicle Type of Vehicle: Registration Number: Drivers Name: Drivers Address: Owners Name: Owners Address: Animal Type of Animal: Do you own the animal? Yes No Please describe how the animal escaped and caused the injury: Attendance | Treatment at the Scene Was Treatment given at the scene? Yes No If “Yes”, by whom? Describe extent of any injuries: Was Ambulance, Fire or Police called If so, please advise Station & Officer in attendance: Yes No Were any charges laid or charges pending in respect to this incident? Is so, please advise details: Yes No Other Insurance Are you claiming insurance or compensation from any other insurance company? e.g. Workers Compensation, Traffic Accident Commission, CTP? Yes No