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Personal Accident Claim Form

Personal Accident Claim Form Template for Ireland

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Key Requirements PROMPT example:

Personal Accident Claim Form

"I need a Personal Accident Claim Form compliant with Irish law for a manufacturing company, specifically designed for workplace accidents with multiple witness statements and comprehensive employer liability sections to be implemented by March 2025."

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Document background
The Personal Accident Claim Form is a crucial document in the Irish personal injury claims process, designed to facilitate the systematic collection of information required for assessing accident-related claims. This form must be completed when seeking compensation for injuries sustained in accidents, whether they occurred at work, in public places, or during other activities. It aligns with Irish legislation, including the Civil Liability and Courts Act 2004 and the Personal Injuries Assessment Board Act 2003, and requires detailed documentation of the accident circumstances, resulting injuries, medical treatment received, and financial impacts. The form serves as the foundation for claim assessment by insurance companies or the Personal Injuries Assessment Board, and accuracy in completion is essential to avoid delays or complications in the claims process.
Suggested Sections

1. Claimant Personal Information: Essential details including full name, date of birth, PPS number, contact information, and address

2. Insurance Policy Details: Policy number, type of coverage, and insurance company information

3. Accident Details: Date, time, location, and detailed description of how the accident occurred

4. Injury Description: Detailed description of injuries sustained, affected body parts, and current condition

5. Medical Treatment Information: Details of medical attention received, including dates, healthcare providers, and ongoing treatment

6. Loss Details: Information about financial losses, including medical expenses, loss of earnings, and other related costs

7. Witness Information: Contact details of any witnesses to the accident

8. Declaration and Consent: Claimant's declaration of truth and consent for data processing and medical information retrieval

Optional Sections

1. Third Party Details: To be completed if another party was involved in or responsible for the accident

2. Employment Details: Required if the accident occurred at work or if claiming loss of earnings

3. Previous Claims History: Section for declaring any previous personal injury claims, if applicable

4. Vehicle Details: To be completed if the accident involved a vehicle

5. Property Damage: Details of any property damage sustained during the accident

6. Legal Representation: Details of legal representative if the claimant has appointed one

Suggested Schedules

1. Schedule A - Medical Records Authorization: Authorization form for releasing medical records from healthcare providers

2. Schedule B - Expense Record: Detailed listing of all expenses claimed with supporting documentation

3. Schedule C - Loss of Earnings Calculation: Detailed calculation of earnings lost due to the accident

4. Appendix 1 - Supporting Documents Checklist: Checklist of required supporting documents including medical reports, receipts, and photographs

5. Appendix 2 - Accident Scene Diagram: Template for drawing/describing the accident scene

6. Appendix 3 - Injury Photography Guide: Guidelines for submitting photographs of visible injuries

Authors

Alex Denne

Head of Growth (Open Source Law) @ tiktok³ÉÈË°æ | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co
Relevant legal definitions






























Clauses

























Relevant Industries

Insurance

Healthcare

Legal Services

Financial Services

Occupational Health and Safety

Transportation

Manufacturing

Construction

Retail

Hospitality

Sports and Recreation

Relevant Teams

Claims Processing

Legal

Compliance

Risk Assessment

Customer Service

Document Management

Medical Assessment

Investigation

Policy Administration

Accident Prevention

Relevant Roles

Claims Handler

Insurance Underwriter

Risk Manager

Legal Counsel

Claims Assessor

Insurance Broker

Compliance Officer

Medical Professional

Occupational Health Officer

Personal Injury Lawyer

Insurance Policy Administrator

Health and Safety Manager

Claims Investigation Officer

Industries







Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks,  Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination,  Severance Pay, Governing Law, Entire Agreemen

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