SSF 020 Motor Accident Report

• Job Number

• Site

  Select

• Conducted on

  Date

• Site Supervisor

• Location
  Address

• Yes

  No

  N/A

• All accidents to be reported to the AVIVA accident report line immediately.

• Telephone 0800 246876 and quote Policy Number 100711479CMI

• AVIVA reference number:

• Particulars of Accident

• Date of accident

  Date

• Time of accident

  Date

• Speed of travel (mph)

• Speed of travel of other party (mph), approximately if applicable

• Location
  Address

• Diagram (please name road and indicate traffic direction

  Drawing

• Please indicate damage on your vehicle (mark with X)

  Drawing

• Please indicate damage on other vehicle (mark with X)

  Drawing

• Driver Statement (please state fully what happened)

• For what purpose was the vehicle being used?

• Who do you consider to be at fault?

  You

  Other Party

• Witnesses (please provide contact details)

• Were there any persons injured?

  Yes

  No

• Details any injuries

• Was anyone taken to Hospital?

  Yes

  No

• Who and where?

• Did the Police attend?

  Yes

  No

• Officer name & number

Your Driver Details

• Your Name

  Sign

• Your Address

• Your phone number

• Your date of birth

  Date

• Period full licence held

• Vehicle Make & Model

• Vehicle Registration

• Vehicle Colour

• Mileage

• Number of Passengers

• Have you any current conviction (including fixed penalties) in connection with any motor vehicle?

  Yes

  No

Other Party Driver Details

• Their Name

  Sign

• Their Address

• Their phone number

• Their Insurance Details

• Their Vehicle Make & Model

• Their Vehicle Registration

• Their Vehicle Colour

• Number of Passengers

Report Sign-Off

• I declare these particulars are true to the best of my knowledge

  Sign

• C. G. Comley & Sons Limited T/A Comley Demolition. Registered office: Southern Way, Rye Common, Odiham, Hook, Hampshire, RG29 1HU. Telephone: 01256 702178. Email: comley@comleydemolition.co.uk Company Registration Number: 01672195