ANNEX
PART A
CLAIMS-HISTORY STATEMENT
This claims-history statement is issued in accordance with Article 16 of Directive 2009/103/EC of the European Parliament and of the Council of 16 September 2009 relating to insurance against civil liability in respect of the use of motor vehicles, and the enforcement of the obligation to insure against such liability.
A.
Identity of the issuer of the claims-history statement
1.
Legal name
2.
Member State
3.
Registration number or legal basis
4.
Contact information
Address
Email
Phone
B.
Identity and contact information of the policyholder
5.
Name and surname(s) or legal name
6.
Date of birth (DD/MM/YYYY)
7.
Identification number
8.
Contact information
C
Vehicle(s) insured
9.
Category of vehicle
10.
Make of vehicle
11.
Vehicle identification number
12.
Vehicle registration number or other identifier of the vehicle
D.
Insurance contract(s)
13.
Insurance undertaking
14.
Policy number
15.
Start date of cover (DD/MM/YYYY)
16.
End date of cover (DD/MM/YYYY)
E.
Claim(s)
17.
Date(s) of the accident(s) (DD/MM/YYYY)
18.
Number of claims
19.
Number of claims settled
20.
Shared liability (YES NO)
F.
Additional information under the rules or practices applicable in the Member States relevant to premium discounts or penalties, and on contractual arrangements that impact premium calculation
21.
H.
Date and signature
22.
Name of the person signing
23.
Place and date (DD/MM/YYYY)
24.
Signature
PART B
INSTRUCTIONS FOR FILLING IN THE CLAIMS-HISTORY STATEMENT
Section A: Identity of the issuer of the claims-history statement
The entity issuing the statement shall fill in under Section A information relevant for its identification.
Under item 1 the issuer shall also indicate whether it is an insurance undertaking, or another body empowered to issue claims-history statements.
Under item 2 the issuer shall indicate the country code, in the form of the ISO-alpha-2 country code, identifying the Member State in which it is established.
Under item 3 an insurer shall provide its registration number as provided for under national law or in a manner that is customary in the Member State in which the issuer is established, whereas a body shall indicate the relevant legal basis empowering it to issue claims-history statements.
Section B: Identity and contact information of the policyholder
For information on the policyholder, only fields corresponding to relevant items shall be filled in.
Item 5 shall contain the name and surname of policyholders that are natural persons, and the legal name for policyholders that are legal persons.
Item 6 shall be filled in for natural persons. This information may be omitted where an identification number for natural persons is customarily used in the Member State in which the issuer is established, and such number is provided under item 7.
Item 7 shall only be filled in for legal persons with an identifier as provided for under national law or in a manner that is customary in the Member State in which the issuer is established. It may also be filled in for natural persons where an identification number is customarily used in the Member State in which the issuer is established, in accordance with the specific conditions for the processing of a national identification number or any other identifier of general application.
Under item 8 the issuer is required to indicate the contact information provided by the policyholder if so requested.
Section C: Vehicle(s) insured
Section C shall contain information relevant for the identification of the vehicle or vehicles the use of which is covered by the insurance contract or contracts. Each vehicle shall be indicated in a separate line.
Item 9 shall be completed with the category of the vehicle:
A:
Car
B:
Motorcycle
C:
Lorry or tractor
D:
Cycle fitted with auxiliary engine
E:
Bus
F:
Trailer
G:
Others
Item 10 shall be completed with the make of the vehicle. The model may also be indicated.
Item 11 on the Vehicle Identification Number (VIN) shall be completed when available to the issuer.
Item 12 on the vehicle’s registration number shall be completed when available to the issuer. Where neither the vehicle’s registration number nor the Vehicle Identification Number is available, other identifiers of the vehicle such as the chassis number, the engine number or the serial number shall be indicated instead.
Section D: Insurance contract(s)
Information under Section D shall identify some key elements of the contract(s). It may include several contracts depending on whether the issuer is aware of them. Each contract shall be indicated in a separate line. Where the issuer of the claims-history statement is not an insurance undertaking, the relevant insurer shall be listed under item 13.
The start date means the date when the insurance cover provided by the contract begins. The end date of the contract means the date on which the insurance cover ceases. In the absence of a known end date of the contract, item 16 shall contain the mention ‘unknown’.
Section E: Claims
Under item 17, the issuer shall indicate the date(s) of accident(s), if any.
Under item 18, the issuer shall indicate the number of claims per accident. Where no claims exist, this shall be clearly indicated.
Under item 19, the issuer shall indicate the number of claims settled per accident.
Item 20 shall include information on the fact that the policyholder is not entirely liable for the damage caused in an accident (i.e. the liability ratio is lower than 100 %) where the insurer is in possession of such information.
Section F: Other relevant factors
Item 21 allows issuers to detail additional information relevant under the rules or practices applicable in a Member State. This shall include any information available to the issuer which is relevant for the purpose of considering premium discounts or penalties under existing national law, national practices or specific contractual arrangements that have an impact on how a premium is calculated. This may also include information on designated drivers and whether they caused the accident.