MOTOR VEHICLE ACCIDENT REPORT FORM

"*" indicates required fields

Section 1 - Assured

Policy/certificate number*

Business Name*

Address*

Street Address Address Line 2 City County Postcode

Telephone number*

Occupation(s) in full*

Is the Insured registered for VAT?*

Section 2 - Driver

Full Name*

First Name Last Name

Address*

Street Address Address Line 2 City County Postcode

Date of birth*

License Particulars of driver

Driver Number*

Date test was passed*

Groups/categories*

Delete as appropriate

Has the driver any motoring convictions, fixed penalties or pending prosecutions?*

if 'yes' please state*

Does the driver have any medical conditions or disabilities?*

Details*

Section 3 - Vehicle

Make*

Model*

Colour*

GVW

Commercial vehicles only

Cubic capacity*

Registration number*

Year of manufacture*

Mileage at date of accident*

Section 4 - General

Is the vehicle damaged?*

If 'yes' please state*

Section 5 - Other parties (1)

other owners/drivers

Name

Full name

Address

Street Address Address Line 2 City County Postcode

Telephone number

Make of vehicle

Registration of vehicle

Insurers name

Insurers address

Street Address Address Line 2 City County Postcode

Policy number

Details of damage to other persons vehicle or property

Section 5 - Other parties (2)

other owners/drivers

Name

Full name

Address

Street Address Address Line 2 City County Postcode

Telephone number

Make of vehicle

Registration of vehicle

Insurers name

Insurers address

Street Address Address Line 2 City County Postcode

Policy number

Details of damage to other persons vehicle or property

Section 6 - Details of injured persons

Please give name, age, nature of injury (if a passenger the registration number of the vehicle they were travelling in)

Name

Gender

Age

Approx.

Registration

or details of vehicle if not known

Injury

Section 7 - Accident Details

Date of Accident*

Time of Accident*

Location*

Street or Road or Town

Which speed limit was applicable?*

Speed of your vehicle*

Please state weather conditions*

Did Police attend or were they informed?*

If 'yes' give name and number of Constable and address of station*

Witness

Witness Name

First Last

Was the witness a passenger in your vehicle?

Witness Address

Street Address Address Line 2 City County Postcode

Describe fully what happened*

Who was to blame? Explain why.*

Sketch plan

Please include: - Paths taken by all parties prior to accident - Position of all parties at the time of accident - Width of road - Position of any road signs or markings

Section 8 - Declaration

I/We declare that these details are true in every respect. I/We understand that you may seek information form other insurers to check the answers I/we have provided.

Signature*

DATE*

This field is for validation purposes and should be left unchanged.