Motor vehicle Accident report form

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1 Motor vehicle Accident report form The issue of this form is not an admission of a claim Insurers maintain a motor insurance anti-fraud and theft register and exchange information with each other to prevent fraudulent claims Any claim under the policy may affect the no claim discount if applicable Insurers and their agents share information with each other to prevent fraudulent claims and for underwriting purposes via the Claims and Underwriting Exchange register, operated by Insurance Database Services Ltd and via the Motor Insurance Anti-Fraud and Theft Register, operated by the Association of British Insurers. Section 1 -Insured Policy/certificate number Company code fleet only Full name Mr/Mrs/Miss/Ms/title in full including postcode Telephone number home business Occupation(s) in full Is the insured registered for VAT? Section 2 -Driver or person in charge of vehicle at time of accident Name full name must be given in every case Mr/Mrs/Miss/Ms/title in full including postcode Date of birth Licence particulars of driver Driver number Date test was passed Groups/categories delete as appropriate Is it provisional? If 'yes' date licence issued DL 196 obtained? motorcycles only If HGV/LGV or PSV/PCV licence held give: Number Groups/categories delete as appropriate Expiry date If taxi please give badge number continued

2 2 Driver - continued Has the driver any motoring convictions, offences including fixed penalties or any pending prosecutions during the past 5 years? If 'yes' please give details Date of Date of Disqualifying Conviction Offence code offence Fine period Does the driver have or have any history of defective vision or hearing not corrected by glasses/contact lenses or hearing aid diabetes or any disease or physical or mental infirmity or fits of any kind? If 'yes' give full details Was the vehicle being driven with the Was the driver in the Insured's employ insured's knowledge and permission? at the time of the accident? Section 3 -Vehicle Make Model Colour GVW commercial vehicles only Cubic capacity Registration number Year of manufacture Mileage at date of accident Who is the legal owner of the vehicle and/or trailer Is the owner registered for VAT? Is there any leasing or hire purchase agreement? leasing agreement? Hire purchase agreement? If 'yes' give a, name and address of HP or leasing company b, agreement number Was the vehicle being used for Business Pleasure business or pleasure? For what purpose was the vehicle being used? Give brief details of damage If you have already notified details of damage to your vehicle by telephone please tick Section 4 -General NB Please note that unless you state otherwise, we will deal with damage to your vehicle if covered and with any ciaim(s) made against you by any other parties - any claim under your pol/cy may prejudice your no claim discount. Do you wish to claim for damage to your vehicle under your own Norwich Union policy if covered? Insured's vehicle -If you are claiming under your own Norwich Union policy for damage to your vehicle please complete the following: Is your vehicle mobile? 2 Continued

3 Section 4 - General - continued What is its current location? give name. address and telephone number of garage If applicable Is it at a Norwich Union Select Repairer? If 'no' can it be moved to a Select Repairer? Please note Select Repairer applies to Private Car policies only Private cars only If 'no' or if the vehicle is not insured under a Private Car policy please include a repair estimate with this form Note If your vehicle Is moved to a Select Repairer then if cover operates they will handle authorlsatlon of repairs direct with us and can seek approval to start work Immediately. In the event of the vehicle being uneconomical to repair may we move it to a place of free storage in order to minimise storage charges? Point of impact to your vehicle Section 5 - Other parties other owners/drivers First owner/driver Second owner/driver Name Telephone Make and registration number of vehicle Insurers name and address Policy number Details of damage to other persons vehicle or property Section 6 -Details of injured persons Important This section must be completed as fully as possible Please give name, age, nature of injury and if a passenger the registration number of the vehicle in which they were travelling. First person Name Male/ approx Second person Name Male/ Approx continued 3

4 Section 6 - Details of injured persons -continued Third person Name Male/ approx Were they wearing seat belts or helmets as appropriate? Where more than three people injured? If no one was injured please tick box First person Second person Third Person Section 7 -Accident details Date and time of accident Date Time am/pm Location street or road and town Which speed limit was applicable? Speed of your vehicle Please state weather conditions Did police attend or were they informed? If 'yes' give name and number of constable and address of station Have you received any summons or notice of intention to prosecute arising from this accident? If 'yes' give full details Witnesses -tick box on right hand side if witness was a passenger in your vehicle First witness -name Second witness -name Third witness -name Describe fully what happened continue on separate sheet/overleaf if necessary 4 Continued

5 Section 7-Accident details -continued Describe fully what happened continued from previous page Sketch plan -please include a. The paths taken by all parties leading up to the accident b. The position of all parties at the time of the accident c. Width of road d. The position of any road signs or warnings Do you consider the other party was to blame. If so how? Section 8 -Declaration I/We declare that these details are true in every respect I/We understand that you may seek information from other insurers to check the answers I/We have provided. Signature Date Failure to answer any question may cause delay When completed please return this form without delay to Norwich Union, either direct or via your insurance agent. Information requested herein is required to enable ourselves and our solicitors to give advice thereon and to conduct any litigation which may ensue. 5

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