Information
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Name of Client
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Date and Time
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Location
Vehicle Accident
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Driver Name
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Customer Name
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Vehicle Make
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Vehicle Model
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Vehicle Colour
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Vehicle Year
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Vehicle Registration Number (VRN)
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Date & Time of the Accident
Conditions
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Weather Conditions
- clear
- foggy
- rainy
- snowy
- icy
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Visibility Conditions
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Road Conditions
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Traffic Conditions
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Accident Location
Witness Details
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Witness Name
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Witness Address
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Witness Phone Number
Other Party Details
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2nd Party Name
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2nd Party Address
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2nd Party Phone Number
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2nd Party Vehicle Make
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2nd Party Vehicle Model, Colour & Year
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2nd Party Vehicle Registration Number
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List the 2nd Party's Insurance Company and Policy Number
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List the 2nd Party's Insurance Phone Number
Passengers/Injuries
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How many passengers were inside the other vehicle at the time of the accident?
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Where there any injuries?
Police Information
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If Police called, list Police Officer's Name
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Police Officer's Badge Number
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Police Officer's Telephone Number
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Police Log Number
Description of Accident and Damages
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Full Description of Accident
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Mark damages on the image below as per the key.
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Damage 1
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Description of Damage 1 - where is the damage located, how much damage and what is the damage?
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Damage 2
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Description of Damage 2 - where is the damage located, how much damage and what is the damage?
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Damage 3
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Description of Damage 3 - where is the damage located, how much damage and what is the damage?
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Drivers' Signature
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Customer's Signature
