Motor Accident Report Form

Insurance company name: Aviva
Contact number for third party: 0113 393 6300
Insurance Policy number: 100756246CMI

Depot:

Driver Details
Your Full Name:

Your Address:

Postcode:

Job Title:

Daytime Telephone number:

Your Age:

was the driver licensed to drive:

Full license held since:

Company employee:

Driver authorised by company:

If non-employee, state reason for driving:

Date:

Has the driver been refused motor insurance:

If yes, please give full details:

List all driving convictions with dates:

Has the driver received notice of an intended prosecution for this accident:

If yes, please give full details:

Has the driver had an accident in the last 5 years?:

If yes, please give full details:

Company vehicle details

Registration number:

Make:

Model:

is the company owned, leased or hired:

If leased or hired, please give name of the lease/hire company:

Accident Details
was the vehicle being used for Business, Pleasure, to & From work:

Date:

Time:

Location:

Weather conditions:

Conditions of road (good/ average/ poor):

Speed of company vehicle:

Speed of third party vehicle:

State warnings given by you:

State warnings given by third party:

Drivers Statement
Please explain fully and clearly what happened:

Accident damage
Please take photos (If possible) of the scene of the accident including road signs, signals and surroundings. type yes if you haven taken photos :

Who do you consider to be at fault and why:

Third Party Details
Driver name:

Their address:

Telephone number:

Registration number:

Make:

Model:

Their insurance details & Policy number:

Photo (if possible) vehicle damage to all involved, if unable to photo please type out what damage is present:

Which vehicles were driven from the accident:

If recovered, where were they taken to:

Name(s) of injured parties:

Vehicle:

Nature of injury:

Did the police attend:

Were details taken:

Name & Number of attending officer(s):

Station of Police attending:

Were the police notified at a later date:

If yes, please advise details of station reported to:

Police reference number:

Witness name:

Witness address:

Passenger in company vehicle:

Statement of truth
Proceeding for contempt of court may be brought against anyone who makes or causes to be made a false statement in a
witness statement verified by a statement of truth. I believe that the facts stated in this witness statement are true. I have read
and understood the declarations above. *DRIVER'S NAME (you) & DATE:

Any Other relevant Comments/Information: