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Please complete this form and sign and date it. Do not delay returning the form if you do not have an answer to each question.

YOUR DETAILS
Title:
First Name:
Surname:
Client Address
 
 
Telephone Number
Day
Eve
Mobile
Date of Birth
N.I. Number

EMPLOYMENT DETAILS
Full Name of Your Employers
Address of Your Employers
 
 
Post Code
Your Occupation / Job Title

ACCIDENT DETAILS
Date of the Accident
Time of the Accident
 (HH)  (MM)
Exactly where did the accident happen
Were Your a Driver Passenger or Pedestrian
Driver Passenger Pedestrian
If you were a driver or passenger, please answer the following:
Yes No
If you were inside a vehicle were you wearing a seatbelt?
Yes No
Do you own the vehicle you were in?
Yes No
(If not who owns the vehicle you were in?)
Please confirm the following details about the vehicle Make & Model
Registration Number
Vehicle Insurers Name
Vehicle Insurers Address
 
Policy Number
What type of insurance cover
Fully Comp TPF & T*
If you own the vehicle has it been?
Repaired Written off?*
Is the vehicle in storage?
Yes No
If yes, where is it being stored?
Please note that if your vehicle is incurring storage charges, it should be moved to free storage as soon as possible. It is your common law duty to mitigate your loss, which means you must try to keep any losses to a minimum.  
You may not be able to recover all of the storage charges if you fail to mitigate your loss.  
Have you had to or are you hiring another vehicle whilst your vehicle is out of use?
Yes No
If yes, Please confirm  
Name of Hire Company  
Address of Hire Company  
Please note that it is your common law duty to mitigate your loss, which means you must try to keep any losses to a minimum. Therefore do not hire a vehicle for longer than is absolutely necessary and only hire a like for like vehicle. You may not be able to recover all of the hire charges if you fail to mitigate your loss.

OTHER PASSENGERS
Were there any other passengers in the vehicle or if you were a pedestrian, was anyone else hurt?
Yes No
If yes, Please provide their names and addresses and contact details  
(4d) Independent referee’s statement:  
Name
Address
 
 

THE RESPONSIBLE PARTY'S VEHICLE & INSURANCE DETAILS
Please provide the following information about the other party.  
Name(s)
Address(es)
Vehicle Make(s) & Model(s)
Registration Number(s)
Vehicle Insurers name(s)
Vehicle Insurers address(es)
Policy Number(s)

POLICE INVOLVEMENT
Was the accident reported to the Police
Yes No
(If Yes, please answer the following questions)
Who Reported to the Police?
What is the Police Accident Reference Number?
What is the name and Collar Number of the Police Officer(s)
Which Police station are they based at?

WITNESSESES/EVIDENCE
Were there any witnesses to the accident? If yes, please provide contact details below:
Yes No
Witness 1:
Name
Address
 
 
Telephone Number
 
Witness 2:
Name
Address
 
 
Telephone Number
If there are any other witnesses, please insert their details in the right hand column.
Name
Address
 
 
Telephone Number
Please note that independent witnesses will not be passengers, friends or relatives. If the witness is a friend / relative / family member it is still possible to use their evidence but the weight attached to is it generally lower than a fully independent witness. If the witnesses you list here are friends/family please indicate this.
Do You Know any of the Witnesses?
Yes No
(If yes, which witnesses do you know?)

DESCRIPTION

PLEASE PROVIDE A FULL DETAILED DESCRIPTION OF THE ACCIDENT (And if possible a sketch. Please attach file.)
Who Reported to the Police?
 

STATEMENT OF TRUTH

I believe the content of this my statement to be true
 Accept
Date