The Accident Claim Form is a critical document used in Belgium for reporting and documenting accidents for insurance and legal purposes. It is designed to comply with Belgian civil law, particularly Articles 1382-1386 of the Belgian Civil Code, and the Law of 4 April 2014 on Insurance. This form should be used whenever an individual needs to report an accident and seek compensation for injuries or damages, whether it's a workplace incident, traffic accident, or personal injury situation. The document captures essential information including personal details, accident circumstances, witness statements, medical information, and evidence of damages, while ensuring compliance with GDPR requirements for personal data protection. It serves as the foundation for insurance claims processing and potential legal proceedings, making it essential for proper documentation and claim resolution.
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1. Personal Information: Claimant's details including full name, address, contact information, national registry number, and insurance policy details
2. Accident Details: Date, time, location, and detailed description of how the accident occurred
3. Involved Parties: Information about all parties involved in the accident, including witnesses, other victims, and potential responsible parties
4. Injury Description: Detailed description of injuries sustained, medical treatment received, and ongoing health issues
5. Property Damage: Description of any property damage resulting from the accident
6. Authority Involvement: Details of police reports, emergency services involvement, and any official report numbers
7. Claim Details: Specific compensation being claimed, including medical expenses, property damage, lost wages, and other damages
8. Declaration: Formal declaration of truth and accuracy of the information provided, with space for signature and date
1. Work-Related Information: Additional section required if the accident occurred during work activities, including employer details and workplace circumstances
2. Vehicle Information: Required for traffic accidents, including vehicle details, insurance information, and driver's license information
3. Medical History: Optional section for relevant pre-existing conditions or previous injuries that may affect the claim
4. Third-Party Insurance: Required when another party's insurance is involved, including their insurance company details and policy numbers
5. Witness Statements: Optional detailed statements from witnesses, to be included if witnesses were present at the accident scene
1. Medical Documentation: Copies of medical reports, bills, and treatment records
2. Photographic Evidence: Photos of injuries, damage, and accident scene
3. Expense Records: Detailed list and proof of all expenses claimed
4. Official Reports: Copies of police reports, workplace incident reports, or other official documentation
5. Supporting Documents: Additional evidence such as receipts, wage statements, expert opinions, or other relevant documentation
6. Privacy Notice: GDPR-compliant privacy notice explaining how personal data will be processed
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