MOTOR ACCIDENT REPORT FORM

IMPORTANT NOTES

Please complete ALL sections of the form.
If a question does not apply write “not applicable”. Crossing out a question may cause delay.
You must immediately send all letters received from other parties, to us without answering them, when it is alleged the insured driver is responsible. We will deal with the correspondence as necessary.
Should the insured driver receive a summons in respect of motoring offences arising from this incident then we must be immediately notified in order that the question of legal representation may be considered.
If you need more space to answer any of the questions please use a separate sheet of paper but please make sure you attach it to this form.
When describing what happened it will help us to protect the insured driver’s interests if the following could be included when applicable:
- a.
  
  Weather conditions
- b.
  
  State of the road’s surface
- c.
  
  Speed limit
- d.
  
  The lighting being displayed by the vehicles
- e.
  
  The signals being given by all vehicles
- f.
  
  The steps taken by the drivers involved to avoid the incident
- g.
  
  If street lights were installed and illuminated
- h.
  
  Whether any of the drivers were under the influence of drink or medication
- i.
  
  Details of conversations between the drivers at the scene or later
Please let us know the reasons if you blame another party, yet are not pursuing any claim against them in respect of losses not covered under your policy. If you have a representative acting for you such as a solicitor it would be of assistance if you could advise their name, address and reference number.

WINDSCREEN CLAIMS

If you are making a claim for windscreen or window glass breakage only, there is no need to complete this form. Send the bill for the repair together with your policy number to us.

REPAIR PROCEDURES

If you are able to drive your vehicle safely then please obtain an estimate for repair and send it to us as soon as possible. If your vehicle is not drivable please telephone us immediately for further instructions.

WHAT IS NOT COVERED

You may have to meet various expenses which are not covered by your policy. The most common are: an excess on your policy, out of pocket expenses, traveling costs, loss of earnings, the hire of another vehicle whilst yours is being repaired. Accessories or special parts may not be covered, unless previously advised to us.

THE INSURED

Name:

Policy No.:

Address:

Telephone:(Home)

Telephone:(Work)

Telephone:(Cell)

Employer:

Occupation:

THE DRIVER

Name:

Driver’s License No.:

Address:

Date of Issue:

Occupation:

Type of License:

FULL

PROVISIONAL

Telephone:(Home)

Telephone:(Work)

Telephone:(Cell)

Date of Birth:

Date of Passing Driving Test:

N.I.B. No.:

Has the Driver been involved in any previous accidents in the last five (5) years?

Yes

If ‘YES’, please give details.

Has the Driver been prosecuted for any motoring offence?

Yes

If ‘YES’, please give details.

Does the Driver own another vehicle?

Yes

If ‘YES’, give details of Insurers:

THE PARTIES

PLEASE GIVE DETAILS OF ALL PARTIES INVOLVED INCLUDING PEDESTRIANS AND OWNERS OF ANY PROPERTY DAMAGE (WALLS, FENCES, ETC.)

NAME: (1)

NAME: (2)

ADDRESS: (1)

ADDRESS: (2)

VEHICLE: (1)

VEHICLE: (2)

PROPERTY: (1)

PROPERTY: (2)

DAMAGE: (1)

DAMAGE: (2)

INSURERS: (1)

INSURERS: (2)

PASSENGERS:

(a) in Insured Vehicle

(b) other Vehicle(s)

INJURIES

Name:

Nature of injuries:

ADDRESS:

THE WITNESSES

Were particulars of the accident taken by a Police Officer?

Yes

If ‘YES’, please state

(a) Name/No:

(b) Station:

(c)

Was a notice of intended prosecution given?

Yes

If ‘YES’, give details

Name & Address of independent witnesses:

DESCRIPTION OF ACCIDENT

PLEASE STATE FULLY THE CIRCUMSTANCES OF THE ACCIDENT AND SHOW BELOW BY WAY OF A SKETCH THE ACCIDENT LOCATION AND POSITION OF VEHICLE(S).

I/WE HEREBY DECLARE THAT THE INFORMATION GIVEN ON THIS FORM IS TRUE TO THE BEST OF MY/OUR KNOWLEDGE.

MOTOR ACCIDENT REPORT FORM

IMPORTANT NOTES

WINDSCREEN CLAIMS

REPAIR PROCEDURES

WHAT IS NOT COVERED

THE INSURED

THE VEHICLE

THE DRIVER

THE ACCIDENT

Please give details of the following:

THE PARTIES

INJURIES

THE WITNESSES

DESCRIPTION OF ACCIDENT

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