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SECTION F - OFFENDING VEHICLE DETAILS:

36. Registration Number:

37.Make & Model of Vehicle:

38. Country of Registration:

39. Vehicle Owner:

40. Vehicle Driver (at time of accident):

41. Vehicle Owner Address & Telephone No.:

42. Vehicle Driver Address & Telephone No.:

43. Vehicle Insurer:

44. Policy Number:

45. Expiry Date:

46. What steps have been taken to establish if vehicle was insured:

47. Why does the claimant believe the vehicle to be uninsured:

48. If Foreign Registered Vehicle give Green Card No. & include photocopy if available: Green Card No.

49. Any other vehicles involved in accident: Yes/No

(If yes please supply details :)

I confirm all the above information to be true and accurate. Signature & Date:

_______________________________________________________________________________________

For information on Terms & Conditions which apply in making a claim for compensation from MIBI please refer to the relevant MIBI Agreement available from www.mibi.ie

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