PRIVATE AND CONFIDENTIAL

Third Party Accident/Loss Report Form

For a third party claiming against a PICL insured.

Supporting files stay in private PICL storage.

Claim Header

Date

Claimant

Name of Owner/ClaimantAddressProfession/OccupationPhone NoVehicle NoMake of VehicleEmployerAddressName of Insurance CompanyType of CoverageEmail (W)Email (H)VAT No

Privacy and consent notice

PICL collects the information in this third-party accident/loss report, including contact details and any uploaded documents, to assess insurance, claims, KYC, compliance, fraud prevention, customer support, and required record keeping.

Documents are stored in private systems and are shared only with authorized PICL staff, service providers, regulators, or legal authorities where needed. Retention periods and legal wording are placeholders for PICL legal review.

For privacy questions or complaints, contact PICL compliance. You may also contact the Trinidad and Tobago Information Commissioner where applicable.

I consent to PICL collecting, using, storing, and sharing this information for the purposes above. Version legal-placeholder-2026-07-02.