Accident Report

Driver and Vehicle Details

Name:
Address:
Telephone:
Email
Date of Birth Under 26 years?   Yes No
Use at time of incident
No. of years Driving licence held
No. of years Hire and Reward licence held
last incident/Claims in last 3 years
List conviction in last 3 years

Incident Details

Date of Incident
Time of Incident
Location of Incident
Incident Details
Speed of Vehicle Prior to Incident
What lights were displayed
What Signals were given
What Warnings were given
Where there is any other party involved?Yes No
Was the policyholder driver injuredYes No
No. of vehicles involved
how many people were in policyhoder vehicle(including driver)?
How many people were paying a fare
were any passenger in the policyholder's vehicle injured?Yes No
were any passenger in the policyholder's vehicle injured?Yes No How Many
How many people were there in the third party vehicle?
were any passenger in the third party's vehicle injured?Yes No How Many
Details of anybody else injured (eg. pedestrian, cyclist etc)
Weather conditions:    Road conditions:
Did anyone admit the blame at the scene of the incident?
Do You Accept Liability Yes No


Does Your Vehicle Operate a CCTV or telematic device?    Yes No
Is this equipment in full working order?   Yes No
was it switched on at anytime at the time of incident?   Yes No
if no then provide explanation

Vehicle Damage

Discription of Damage
Estimate for repair
Damage covered? Yes No Storage Charges being incurred Yes No
Claiming for own damage Yes No Permission to move Vehicle Yes No
Vehicle drivable? Yes No Engineer inspection arranged? Yes No
Vehicle Secure? Yes No Name of Engineer
is the family financed? Yes No
Finance company details
Agreement Number
Where can vehicle be inspected:

Third Party details

headings123456 Registration No.
Make Model
Damage
Name
Adress
Contact Details
Insurance Details
Driver,Passesenger,
padestrian

Injured

Injury Details (please give details of all injuries sustained by person above) NameInjury DetailsWearing SeatbeltEstimated Age








Property Damaged

Description of DamageWearing SeatbeltOwner Address






Witnesses

NameAddressContact DetailsLocation at the time of Accident








Emergency Services

Reported to the Police Yes No If yes Please comlete the details
Police Attended Scene? Yes No Ambulance called? Yes No
Was anyone breathalysed? Yes No
if yes who? Policyholder third party
if so what was the result? Policyholder: Positive Negative
Third party:  Positive Negative
Reported to the Police
Officer No.
Police Station
Police Contact No.
Police Reference No.

Declaration

Please confirm that you have advised the person reporting this incident of the following by ticking the APPROPRIATE box below.

Insurers pass information to the Claims and Underwriting Exchange Register, run by Insurance Database Services Ltd (IDS Ltd) and the Motor Insurance Anti-Fraud and Theft Register, run by the Association of BritishInsurers (ABI). The aim is to help us to check information provided and also to prevent fraudulent claims. Under the conditions of your policy, you must tell us about any incident (such as an accident or theft) which may or may not give rise to a claim. We will pass information relating to this incident to the registers.

We will also retain this information for future policy processing and claims handling to prevent and detect fraudulent claims.

When providing the above information you confirmed the following :

• We may ask for information from other insurers to check the answers you have provided.

• If false or inaccurate information is provided or if we have a suspicion of fraud this may be recorded and details passed to fraud prevention agencies.

• You will undertake to assist the company in dealing with this matter and understand that all correspondence or legal proceedings must be submitted to the company unanswered immediately following receipt and that failure to do so could result in the company refusing indemnity in respect of this incident.

Customer Adviced Third Party Adviced

Please confirm by ticking the box below that you have checked the following:

The damage is insured by the Policy, and - The driver was insured to drive the vehicle at the time of the accident/incident, and

- The vehicle was being used in accordance with the Policy at the time of the accident/incident, and - The premium had been paid prior to the accident/incident

Engineer AdvisedYes No If yes please name Repairs Authorised Yes No
Car Hire arranged through Central Cab CarYes No
I confirm the above is in order Completed By:

Uninsured losses and sending complete form

Finally to help us process your claim as fast as possible select one of the options below followed by its corresponding email button

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