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MIBI Ref.

CLAIM NOTIFICATION FORM

Please note that only receipt by MIBI of a fully completed claim notification form will constitute formal notification of a claim which should be returned to MIBI, Insurance House, 39 Molesworth Street, Dublin 2. Please use BLOCK CAPITAL letters only when completing this form.

Privacy Notice: The information you provide to us as part of your claim application will be processed by us to confirm your identity, process your application and to record and cross reference particulars of your claim in insurance industry databases for fraud prevention purposes. In certain cases, this may involve the sharing of your information with other insurance providers and private investigators. Guidelines for sharing of information in this regard are contained in a Code of Practice on Data Protection for the Insurance Sector which has been approved by the Data Protection Commissioner. For full details see the Data Protection Notice on our website www.mibi.ie.

1. Title: Mr/Mrs/Ms/etc.

SECTION A - CLAIMANT DETAILS 2. Male/Female 3. Date of Birth:

4. Name:

7. Address:

  • 5.

    Email address:

  • 6.

    Telephone No:

  • 8.

    PPS/Company Number:

9. Occupation:

  • 10.

    Registered for VAT: Yes/NO

  • 11.

    What is the claimant’s involvement in accident:

Driver, Passenger, Pedestrian, Vehicle Owner, Property Owner, Cyclist, Other (please specify):

SECTION B - CLAIMING FOR: 12. Vehicle Damage: Give details of vehicle damage sustained:

If any of the following documents are available you must supply them with this form: (a) estimate for repairs (b) engineers report (c) photographs of damaged vehicle.

Note: An excess is applicable to MIBI Vehicle Damage Claims in certain specific circumstances.

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