Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
Untitled Page
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MOTOR VEHICLE ACCIDENT REPORT FORM
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Drivers Details
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Drivers Name
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Drivers Address
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Drivers DOB
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Date Driving Test Passed
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Licence Groups
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Does the driver have any medical conditions disclosed to the DVSA?
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Enter details here
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Does the driver have any convictions on their licence?
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Enter details here
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Accident Details
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Date & Time of Accident
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Location
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Road Conditions
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Please state Road Conditions
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Weather Conditions
- Sunny
- Raining
- Snowing
- Foggy
- Windy
- Other
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Please state weather conditions
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Dashcam / CCTV
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Estimated Speed
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Was Driver responsible?
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Would the driver be willing to attend court?
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Accident Description
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Describe what happened
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Accident Diagram
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If photo's taken, please detail how many
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Motor Vehicle Accident Report Form
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Policy Holder Vehicle Details
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Make of Vehicle
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Model of Vehicle
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Registration Number
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Trade Plate
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Mileage
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Purpose of Journey
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Child Occupants
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Name of Hire/Lease Company
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Description of Damage
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Show Areas of Damage
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Was there any property damage as a result of the accident?
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Please state damage (add photos)
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Is the vehicle roadworthy?
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Were any photos taken at the scene?
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Third Party Vehicle Details
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Make of Vehicle
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Model of Vehicle
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Registration Number
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Trade Plate
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Child Occupants
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Description of Damage
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Show Areas of Damage
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3rd Party Drivers Name
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3rd Party Drivers Address
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3rd Party Drivers Contact Number
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Owners Name (If different to above)
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Owners Address (If different to above)
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Owners Contact Number (If different to above)
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3rd Party Drivers Insurance Details
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Injuries
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Are there any injured parties?
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If Yes, How many Injured Parties?
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*If there are injured parties, please complete the following by clicking on the + sign below*
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Name
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Address
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Details of Injuries
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Policy Holder or Third Party
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Witness Details
Witness Details
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Name
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Address
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Contact Number
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Police Details
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Did Police Attend?
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Officer(s) Name(s) & Badge Number(s)
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Reference Number (Given by Police)
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Station:
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Drivers Statement
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Did the drivers make a statement?
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Any Other Information:
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Declaration: I declare to the best of my knowledge and belief that the details given are true. Information provided within this report will be shared with other parties. For further information please refer to our privacy Policy.
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Signed Policy Holder
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Signed Driver
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Date
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Interviewers Details
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Name
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Position
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Date & Time
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Phone Number
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Email Address
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Signature
