Approval of Certificate Form for Insured Events Under Compulsory Motor Vehicle Owners' Civil Liability Insurance

STATE REGISTER OF LEGAL ACTS OF THE REPUBLIC OF AZERBAIJAN Act Type: RESOLUTION OF THE BOARD OF THE MINISTRY OF FINANCE OF THE REPUBLIC OF AZERBAIJAN Approval Date: 24.01.2014 Registration No. Q-03 Title: On approval of the certificate form for cases that can be considered insured events under compulsory insurance of motor vehicle owners' civil liability Official publication source: Effective Date: 06.02.2014 Index Code According to the Unified Legal Classification of the Republic of Azerbaijan 090.050.030 Registration Number of the State Register of Legal Acts 15201401240003 Date of Entry of the Legal Act into the State Register of Legal Acts 05.02.2014 To ensure the implementation of paragraph 1.2 of Decree No. 937 of the President of the Republic of Azerbaijan, dated July 4, 2013, on the application of Law No. 649-IVQD of the Republic of Azerbaijan, dated May 14, 2013, "On Amendments to the Law of the Republic of Azerbaijan 'On Compulsory Insurance," as well as subparagraph 3.1.10 of Decree No. 500 of the President of the Republic of Azerbaijan, dated September 15, 2011, the Board of the Ministry of Finance of the Republic of Azerbaijan HEREBY RESOLVES:

1. To approve the certificate form for cases that can be considered insured events under the compulsory insurance of motor vehicle owners' civil liability (attached).
2. To annul Resolution No. Q-03 of the Ministry of Finance of the Republic of Azerbaijan dated March 15, 2012, on approval of the certificate form for cases that

can be considered insured events under compulsory insurance of motor vehicle owners' civil liability. 3. To instruct the Department of Financial and Insurance Market Regulation and the State Insurance Supervision Service to ensure that this Resolution is submitted to the Ministry of Justice of the Republic of Azerbaijan for inclusion in the State Register of Legal Acts of the Republic of Azerbaijan within 3 days. Samir Sharifov Chairman of the Board, Minister of the Republic of Azerbaijan

Approved Resolution No. Q-03 Board of the Ministry of Finance of the Republic of Azerbaijan January 24, 2014 Stamp of the State Traffic Police Authority CERTIFICATE detailing a case that can be considered an insured event under compulsory insurance of motor vehicle owners' civil liability _______________________________________________________hereby states that on _________ name of the State Traffic Police Authority __________ 20, at___________hour _______________ minutes a traffic accident has occurred at the following address: _______________________________________________________________________ address of the area where the traffic accident occurred Type of traffic accident: _____________________________________________________________________ collision // overturning // hitting a pedestrian / obstacle / other vehicle / animal

1. Information on the PERSON(S) AT FAULT in the traffic accident, based on the effective decision of the body (official) authorized to consider cases of administrative or criminal offenses: Note: If several persons have been identified as being at fault in the occurrence of a traffic accident based on the effective decision of the body authorized to consider cases of administrative or criminal offenses, the information is written in front of the corresponding numbers (No.) in the tables below. 1.1. Make, model and state registration plate of the vehicle No. Vehicle make and model State registration plate

1.2. Owner and driver of the vehicle No. Owner The name (if an individual, surname and patronymic) is to be provided.) Driver at the time of the incident (name, surname and patronymic) 1. 2. 3. Document confirming ownership rights (name of the document, number, by whom and when it was issued) Driver's license (series, number, by whom and when issued) 1. 2. 3.

1.3. Driver's ID card No. Serial number of the ID card, date of issue and issuing authority PIN code of the ID card (first seven of the last eight characters of the last line of the part with the photo) 1. 2. 3. 1.4. Driver’s address No. Registered address Physical address 1. 2. 3. 1.5. At the time of the traffic accident: No. Did the driver have the right to drive the vehicle? Was the driver sober or intoxicated? 1. 2. 3. 1.6. Information about proceedings initiated against the driver No. Type (administrative or criminal) Commencement date Name, surname, position, rank of the official who initiated the proceedings 1. 2. 3. 2. Information on the participants identified as VICTIMS in a traffic accident, the property damaged and the characteristics of the damage, based on the effective decision of the body (official) authorized to consider cases of administrative offenses or criminal cases: NOTE: If two or more people are identified as victims of a traffic accident, except in cases where they are passengers of the same vehicle, information about one of the victims shall be recorded in this reference. Information about the other victims shall be recorded in the appendix to this reference. The appendix shall be filled out separately for each victim. The appendices shall be numbered and attached to this reference.

2.1. Type of damage: _______________________________________________damage caused to health // property // health and property 2.1.1. In case of harm to health No. Name, surname, patronymic of the victim Result of the damage (minor injury // less serious injury // serious injury // disability // limitation of health capabilities // death) 1 2 3 4 5 2.1.2. In case of harm to property

1. Type of property ________________________________________________________________ motor vehicle //house // shop // administrative building // other building, etc.
2. If the damage is caused to a motor vehicle, 2.1) owner’s name (if a legal entity), surname, patronymic, and telephone number (if an individual)

---

2.2) Vehicle’s make, model and state registration plate: ________________________________________________________ 2.3) Name, surname and telephone number of the person driving the vehicle at the time of the incident:_____________________________________________________________________________________________________ 2.4) Name of parts and elements that are obviously damaged, nature of the damage caused to them_________________________________________________________________________________________________________ 3) When damage is caused to real estate and other movable property, its: 3.1) location address ________________________________________________________________________________________________ 3.2) owner’s name (if a legal entity), surname, patronymic, and telephone number (if an individual)

---

3.3) Name, surname and telephone number of the person using the damaged property during the incident:_________________________________________________________________________________________________________ 3.4) Names of the parts that are obviously damaged, nature of the damage to them____________________________________________________________________________________________________________ Attachment: State traffic police officer: __________________________________________________________________ position and rank

---

name, surname and patronymic L.S. Signature: ______________________

Appendix No. ___ to Certificate No. ___ dated _______________ regarding the details of a case that can be considered an insured event under compulsory insurance of motor vehicle owners' civil liability Information about another person identified as a victim as a result of a traffic accident

1. Type of damage: ______________________________________________________________ caused to health // property // health and property
2. In case of harm to health No. Name, surname and patronymic of the victim Result of the damage (minor injury // less serious injury // serious injury // disability // limitation of health capabilities // death) 1 2 3 4 5
3. In case of harm to property 3.1. Type of property

---

vehicle//house // shop //administrative building // other building, etc. 3.2. If the damage is caused to a motor vehicle, 3.2.1) owner’s name (if a legal entity), surname, patronymic, and telephone number (if an individual)

---

3.2.2) vehicle’s make, model and state registration plate:

---

3.2.3) name, surname and telephone number of the person driving the vehicle at the time of the incident:______________________________________________________________________________ 3.2.4) name of parts and elements that are obviously damaged, nature of the damage caused to them___________________________________________________________________________________ 3.3. When damage is caused to real estate and other movable property, its: 3.3.1) location address ________________________________________________________________________________ 3.3.2) owner’s name (if a legal entity), surname, patronymic, and telephone number (if an individual)

---

3.3.3) name, surname and telephone number of the person using the damaged property during the incident:_ __________________________________________________________________ 3.3.4) names of the parts that are obviously damaged, nature of the damage to them____________________________________________________________________________ State traffic police officer: __________________________________________________________________ position and rank

---

name, surname and patronymic L.S. Signature: ______________________