Title Page
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Conducted on
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Prepared by (Name)
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Date of birth
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Location
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Vehicle registration number
Safety
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Are you in a position of safety?
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If safe to do so, get to a safe position, or call 999.
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Is anyone at risk as a result of the incident?
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Do they require emergency help?
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Call 999 for the emergency services
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Are there any immediate risks to property or infrastructure? (I.E Network rail, pylons, building collapse)
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If safe to do so, get to a safe position, or call 999.
Injuries
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Are there any injured parties?
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Do they require immediate assistance?
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Stop this form and contact 999.
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Is there more than 1 injured party?
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Describe injury detail including name of injured party
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Person 1 - Describe injury detail including name of injured party
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Person 2 - Describe injury detail including name of injured party
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Person 3 - Describe injury detail including name of injured party
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Person 4/5/6 - Describe injury detail including name of injured party
Infrastructure
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Has there been any infrastructure damage? (I.E. Bridge strike, pylons, buildings, property, etc.)
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What type of infrustucture?
- Bridge strike or network rail
- Electricity (Pylons/ national grid etc.)
- Building / property
- Other
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Contact Network rail and emergency services (Rail bridge numbers are found on the bridge (see example))
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Contact 105 and emergency services
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Contact emergency services if the building is structurally at risk
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What type of damage has occurred - include as much detail as possible.
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Please describe in detail and contact the emergency services if required
Insurance questions
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Was your vehicle parked / unattended?
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Please give details - location (street name), reason for unattended vehicle etc.
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Were you the driver of the vehicle at the time of the incident?
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Who was driving (Name and date of birth required)
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Have you received any motoring convictions in the last 5 years?
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Please give details of these
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Have you held your licence for more than a year?
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Was there anybody who witnessed the incident?
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Please add details, (Name address, phone number, email address)
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Did any emergency services attend the incident?
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Add any crime reference numbers or reference numbers of attending officer details
Other parties involved
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Vehicle 1 - Name, address, email and phone number
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Vehicle registration and make / model
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How many people were in the vehicle?
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Vehicle 2 - Name, address, email and phone number
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Vehicle registration and make / model
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How many people were in the vehicle?
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Vehicle 3/4/5 - Name, address, email and phone number
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Vehicle registration and make / model
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How many people were in the vehicle?
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Were there any passengers involved?
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Provide details of all passengers -Name, address, email and phone number
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Were any pedestrians involved?
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Provide details of any pedestrians involved - Name, address, email and phone number
Incident details
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Weather conditions
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Location
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Road surface type ( Tarmac, concrete, gravel etc.)
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road speed limit (If known)
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What happened ( Give a full description of what has happened).
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Do you believe you were at fault?
Evidence
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Add photo(s) of the scene showing the entire area from all directions
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Add photos of any damage to all vehicles and or infrastructure / property.
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Add photos of any road signage in the vicinity
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Add photos of all vehicle registration numbers involved in the incident
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Add additional photos of any contributing factors
Incident sketch
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Upload a sketch (plan view) of the incident details
Declaration
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I confirm to the best of my knowledge this is a factual account of the incident
