SPC Motor Incident Report (Same Day Or Next Day- Don't Delay)

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Policy Holder

• Policy Holder : Sovereign Housing Association Ltd
  Policy number : JHA-22S931-0013-52

Driver of Spectrum vehicle

• Name :

• Date of Birth

  Date

• Date Test Passed

  Date

• Address:

• Drivers Details (please provide all details of all previous and pending motoring convictions and any physical or mental infirmity)

Spectrum Vehicle

• Make:

• Model:

• Reg Number:

• Damage sustained in this incident:

• Number of passengers:

• Where is the vehicle now?

• Is the vehicle still in use?

  Yes

  No

  N/A

Third Party Details:

• Name and Address:

• Telephone number:

• Registration number:

• Number of passengers:

• Make/ Model/ Colour of vehicle

• Damage to third party vehicle:

• Name of insurer:

• Policy number:

Personal Injury:

• Please confirm the name of all injured parties. (And the nature and extent of all injuries sustained in this incident)

Witnesses

• Please provide the names, addresses and telephone numbers of all witnesses to the incident. (Please indicate if any of them are known to your driver)

Incident details:

• Date of Incident

  Date

• Time of Incident

  Date

• Location of incident/ Road name

• Town/ City/ Country:

• Road and weather condition:

• What lights were showing on our vehicle/ TP vehicle:

Circumstances of incident

• Please describe what actually happened:

• Is the Spectrum driver to blame for this incident?

  Yes

  No

  N/A

Additional Comments:

• Please provide any further comments on the incident that you would like to bring to our attention:

Drawing of Accident Scene

• Please show road names, numbers or direction of travel of each vehicle:

  Drawing

• Photos of accident and damage to Spectrum and Third Party vehicles

  Media

Declaration I declare that the information provided is true, complete and correctly recorded. I understand that concealment, misrepresentation or false declaration concerning this statement could cause my insurance to be void.

• Name

• Date

  Date

• Signature

  Sign

IA-04-30