Accident Claim Form in the Netherlands

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European Accident Statementaccident statement · front & back

How it works: answer a few simple questions below and briefly sketch what happened. We automatically place all your answers in the right spots on the genuine, official European Accident Statement — exactly the document insurers across Europe accept. You receive it instantly as a fully filled-in PDF you can save, print and sign. No more complicated paperwork.

1Date & time

DateTime

2Location

CountryPlaceStreet

3Injuries?

Incl. minor? Yes No

4Damage to others?

Other vehicles than A/B? Yes No

Other objects? Yes No

If yes: owner/details

5Witnesses

VEHICLE A(you)

6Policyholder

NameAddressPhone / email

7Vehicle

Make & modelPlateCountryTrailer

8Insurer

CompanyPolicy no.Green card / validBroker

Comprehensively insured? Yes No

9Driver

NameDate of birthLicence no.Cat. / valid

10Point of impact

Describe (see sketch)

11Visible damage

12Circumstances

Tick what applies — A left, B right.

A		B
	1. was parked / stationary
	2. was leaving a parking space / opening a door
	3. was parking
	4. was entering a parking area, driveway or unpaved road
	5. was leaving a parking area, exit or unpaved road
	6. was entering a roundabout
	7. was driving on a roundabout
	8. struck the rear (same direction, same lane)
	9. was going in the same direction in a different lane
	10. was changing lanes
	11. was overtaking
	12. was turning right
	13. was turning left
	14. was reversing
	15. encroached on the oncoming lane
	16. was coming from the right (at a junction)
	17. ignored a priority sign or red light
0	Boxes ticked	0

VEHICLE B(other party)

6Policyholder

NameAddressPhone / email

7Vehicle

Make & modelPlateCountryTrailer

8Insurer

CompanyPolicy no.Green card / validBroker

Comprehensively insured? Yes No

9Driver

NameDate of birthLicence no.Cat. / valid

10Point of impact

Describe (see sketch)

11Visible damage

13Sketch of the accident

Background BlankCrossroadsTRoundaboutStraight Width Vehicles: 🚗 Car 🚚 Truck 🚲 Bike 🛵 Moped 🏍️ Motorbike 🚶 Pedestrian Road pieces: ▭ Road ▦ Crossing ⚠ Sign 🚦 Lights ⟳ RotateUndoClear

14Remarks

15Signature

Signature — driver A ✕ Clear

Signature — driver B ✕ Clear

Sign above with your mouse, finger or stylus. Both drivers sign — this is not an admission of liability, it only records the facts. The signatures are placed automatically in the official PDF.

European Accident Statement — Sheet 2/2 · back (complete at home)

Back — complete at home (for your insurer)

Broker claim no. Insurer claim no. Occupation

VAT deductible? Yes No

Mileage Use

Driver authorised? Yes No

If not, why? Estimated amount (€) Repairer

Legal-aid insurance? Yes No

Legal-aid policy

Passenger insurance? Yes No

Passenger policy

Police present? Yes No

Place + report no.

Casualties

	Name	Postcode	m/v	D.o.b.	Type of injury
Vehicle A
Vehicle A
Vehicle B
Vehicle B

Circumstances

Speed A Speed B Speed limit

Built-up area? Yes No

Road type Lanes

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🔒 Saving is done in your own browser (or as a file) — nothing is sent to us unless you click "Send to lawyer".

Download Your Accident Claim Form for the Netherlands

Is there personal injury?

If you, as a driver or passenger, have sustained personal injury in an accident in the Netherlands, you are likely eligible for free assistance from a specialized Personal Injury Lawyer under Dutch law. Want to know more? Get your damages reimbursed.
>>Calculate your pain and suffering compensation (smartengeld) or contact form:

Filling in the Accident Claim Form

Below are some important points to consider:

Fill in the front of the accident claim form together with the opposing party. You can fill in the back later at home;

Ensure that the insurance details and license plate number of the opposing party are filled in correctly;

Make a clear sketch of the situation. Indicate the direction in which the cars were driving and on which side they first made contact;

Tick the correct boxes for question 12 and fill in the total number of ticked boxes under each column;

Ensure that both parties sign the form. Only sign if you agree with the ticked boxes and the situational sketch;

Note the names and addresses of witnesses on the accident claim form. Even if they are co-passengers or family;
Take photos of the situation and the damage to your car;

Keep a copy of the accident report form at home.

juridical assistance and advice for personal injury due to: