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Accident Claim Form Template for Ireland

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Key Requirements PROMPT example:

Accident Claim Form

"I need an Accident Claim Form template for our construction company in Ireland that will be used to process workplace accidents, with specific sections for machinery-related incidents and compliance with 2025 construction safety regulations."

Document background
The Accident Claim Form is a fundamental document in the Irish personal injury claims process, designed to facilitate the mandatory first step of claim assessment through the Personal Injuries Assessment Board (PIAB). This form must be completed before any court proceedings can be initiated, except in limited circumstances. The document collects comprehensive information about the accident, injuries, and losses, serving as the basis for PIAB's assessment of compensation. It must be completed within the statutory limitation period (typically two years from the date of the incident) and requires supporting documentation such as medical reports and proof of expenses. The form is structured to ensure compliance with Irish legislation, including the PIAB Act 2003 and Civil Liability and Courts Act 2004, while remaining accessible to claimants who may be completing it without legal representation.
Suggested Sections

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

2. Accident Details: Specific information about when, where, and how the accident occurred, including date, time, location, and detailed description of the incident

3. Respondent Information: Details of the person or entity against whom the claim is being made, including contact information and any relevant insurance details

4. Injury Description: Comprehensive description of all injuries sustained in the accident, including immediate and developing symptoms

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

6. Loss and Damage: Itemized list of financial losses including medical expenses, loss of earnings, and other accident-related costs

7. Witness Information: Details of any witnesses to the accident, including their contact information

8. Prior Claims History: Declaration of any previous personal injury claims made by the claimant

9. Declaration and Verification: Formal declaration of truth and accuracy of the information provided, with signature and date

Optional Sections

1. Workplace Accident Details: Additional section for accidents occurring at work, including employer details, work practices, and safety measures in place

2. Vehicle Accident Information: Specific details for road traffic accidents including vehicle information, insurance details, and Garda report numbers

3. Public Liability Details: Additional information for accidents in public places, including property owner details and maintenance responsibilities

4. Dependent's Claim: Additional section for claims made on behalf of minors or dependents

5. Emergency Services Response: Details of any emergency services that attended the scene, including reference numbers

6. Third Party Insurance Details: Additional insurance information when multiple insurers are involved

Suggested Schedules

1. Schedule A - Required Documentation Checklist: List of all required supporting documents including medical reports, receipts, and correspondence

2. Schedule B - Medical Assessment Form: Standardized form for medical practitioners to complete regarding injuries and prognosis

3. Schedule C - Expense Record: Detailed log of all expenses and financial losses related to the accident

4. Appendix 1 - Photographic Evidence: Guidelines for submitting photographs of injuries, accident scene, or damage

5. Appendix 2 - Witness Statement Template: Standard format for recording witness statements

6. Appendix 3 - Authorization Forms: Forms authorizing access to medical records and other relevant information

Authors

Alex Denne

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

Relevant legal definitions

































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Relevant Industries

Insurance

Legal Services

Healthcare

Construction

Manufacturing

Retail

Transportation

Hospitality

Property Management

Public Sector

Education

Relevant Teams

Legal

Risk Management

Human Resources

Health and Safety

Compliance

Insurance

Claims Processing

Medical Assessment

Document Management

Customer Service

Relevant Roles

Claims Handler

Insurance Adjuster

Legal Counsel

Risk Manager

Health and Safety Officer

Human Resources Manager

Compliance Officer

Personal Injury Lawyer

Insurance Underwriter

Claims Assessor

Occupational Health Manager

Legal Administrator

Medical Legal Advisor

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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