Contents
THE EUROPEAN COMMISSION,Having regard to the Treaty on the Functioning of the European Union,Having regard to 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 liabilitynote, and in particular Article 16, sixth paragraph, thereof,After consulting the European Data Protection Supervisor in accordance with Article 42 of Regulation (EU) 2018/1725 of the European Parliament and of the Councilnote,After consulting the European Insurance and Occupational Pensions Committee,Whereas:
HAS ADOPTED THIS REGULATION:
Article 1#
Article 2#
Part a — claims-history statement
| 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 | |
| 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 |
| CVehicle(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
Section B: Identity and contact information of the policyholder
Section C: Vehicle(s) insured
Section D: Insurance contract(s)
Section E: Claims
Section F: Other relevant factors
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