SAMPLE FORM.

TO BE USED ONLY AS A MODEL

Annex 2
Insurer: ALLIANZ-TIRIAC UNIT ASIGURARI S.A Date and time of presentation
Data __________________ Hour _____________
The vehicle's introduction into repair document
Existing damages Series................................ No.................................
(to be completed by the investigating inspector) Obtaining from insurance of undue material benefits
is punished according to the Criminal Code
_________________________________________
_________________________________________
_________________________________________ Investigating Inspector, Insured,
signature
_________________________________________ ______________________ ________________
_________________________________________

D E C L A R A T I ON

The undersigned _________________________________ son (daughter) of ______________ and

al______________ born on the date_______________ in the locality ________________________ county /
sector ________ nationality _______________ residing in the locality
____________________________________________ street __________________________________ no.
______ block _____ staircase ______ ap._____county / sector _____________ PIN
______________________________ holder of the serial id _______ no. _____________ issued by
__________________________________ and the driving license category ______ no._____________ issued
by_________________________ at the date__________________ old from _______________ by profession
_________________________ at __________________________ based in the street
__________________________sector _____________ phone home ___________________ work phone
________________________, email __________________________ I declare on my own responsibility the
following aspects regarding the causes and consequences of the occurrence of the road event:

At the date _______________ at around _______________ I drove / parked / stationed the car
no. _____________ brand _______________________ colour __________________ owned by
__________________________ in locality / outside the city _____________________ on street (avenue)
________________________ from direction _______________________________
towards_____________________________________________

When I got to the building with the no. ________ in the intersection ____________________________outside
the city __________________on the highway __________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Damages resulted: ________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

Note: All the spaces marked in the content of the declaration must be filled in correctly.

Date Signature
____________________ _________________________

ALLIANZ-ȚIRIAC UNIT ASIGURĂRI S.A.

Șoseaua Pipera, Nr. 42, Etaj 1 (Camera 1) și Etaj 16,
Sector 2, CP 020112, București, România
Tel: +4 021 200 00 00; Fax: +4 021 200 00 98
www.allianztiriacunit.ro
online.allianztiriacunit.ro
J40/12276/2006. CUI 18892336.
Capital social subscris și vărsat 57.449.520 lei.
Autorizată de Comisia de Supraveghere a Asigurărilor
RA057/06.12.2006, actuala Autoritate de Supraveghere Financiară.
Cod LEI: 5299000TL4WT47U3ZG88.
 The vehicle is CASCO insured with contract no. ______________________________ issued by Insurance
Company__________________________ valid from ____________________ till ________________________

The speed of the vehicle we were driving at the time of the collision was _______ km/h

I declare on my own responsibility that, as a result of the road event, the death or injury of any person or
causing damage to other persons did not result.

Lighting conditions:

- Day light - Low light - Dark

Road condition:

- Dried - Others (wet, frozen, etc.)

Category of vehicle (included in the International Insurance document):

 category “A” car  category ”D” motor bike
 category ”B” motorcycle  category ”E” bus or coach
 category ”C” truck or tractor  category ”F” trailer

Schematic presentation of the accident/even:

At the time of the collision After the collision

sketch of accident sketch of accident

I have taken note of the information Note on the processing of personal data, we have received a copy of it and
we have freely opted for the marked variants of THE CONSENT (if applicable). If I communicate the personal
data of another person, I undertake to send the information Note on the processing of personal data to that
person and declare that I have their consent, in the applicable cases.
Date Signature
___________________ ___________________________

ALLIANZ-ȚIRIAC UNIT ASIGURĂRI S.A.

Șoseaua Pipera, Nr. 42, Etaj 1 (Camera 1) și Etaj 16,
Sector 2, CP 020112, București, România
Tel: +4 021 200 00 00; Fax: +4 021 200 00 98
www.allianztiriacunit.ro
online.allianztiriacunit.ro
J40/12276/2006. CUI 18892336.
Capital social subscris și vărsat 57.449.520 lei.
Autorizată de Comisia de Supraveghere a Asigurărilor
RA057/06.12.2006, actuala Autoritate de Supraveghere Financiară.
Cod LEI: 5299000TL4WT47U3ZG88.