ROAD TRAFFIC COLLISION - SELF REPORTING SCHEME

Transcription

1 Rev 02/15 ROAD TRAFFIC COLLISION - SELF REPORTING SCHEME Please read these notes carefully. The purpose of this form is to reduce the inconvenience to you. Police staff are sometimes not immediately available to record details of your collision/accident. Your co-operation also releases more officers for street patrol. However, if you have any queries concerning the collision/accident or completion of this proforma please contact 101 and ask for the Traffic Process Management Unit. This form should only be completed if: A. You have been involved in a collision where damage occurred but the other driver didn t stop; or B. You have been involved in a collision where damage occurred, you have exchanged details and are alleging the other driver is at fault. Collisions involving minor injury or damage only, which are reported 48 hours or more after the occurrence, will not be recorded. To enable us to investigate Please complete the statement overleaf in BLOCK CAPITALS and in BLACK INK and return it to: TPMU PO Box 6891 Kidderminster Worcestershire DY11 9ER Accident & Process Dept Warwickshire Justice Centre PO Box 3947 Nuneaton Warwickshire CV11 4JU Accident & Process Dept Warwickshire Justice Centre Newbold Terrace Leamington Spa Warwickshire CV32 4EL Please sign at the bottom of each page. The prompt return of this form is required within SEVEN DAYS of the incident occurring so that police can issue statutory notices. Any original note of the registration number of the other vehicle is an important exhibit and must be retained in a safe place and kept for production in court if necessary. Please complete the following and delete as applicable: * delete as applicable 1. Is the accident being reported for insurance purposes only? * 2. Do you have full details of the offending vehicle, i.e. vehicle registration number, make and model? 3. Do you have details of independent witnesses? These can be pedestrians or people travelling in other vehicles who witnessed the collision. * * 4. Are you willing to attend court and give evidence? *

2 Rev 02/15 Page 1 Statement (Criminal Procedure Rules, r27.2; Criminal Justice Act 1967, s.9; Magistrates Courts Act 1980, s.5b) * Delete as necessary and also those questions which are not applicable Name:... (BLOCK CAPITALS) Age if under 21 (if over 21 insert over 21 :... This statement consisting of.. pages each signed by me is true to the best of my knowledge and belief and I make it knowing that if it is tendered in evidence, I shall be liable to prosecution if I have wilfully stated in it anything which I know to be false or do not believe to be true. Dated the... Date of... Signed:... Please ensure each page is signed PLEASE STATE ONLY WHAT YOU SAW YOURSELF 1. DETAILS OF THE COLLISION/ACCIDENT Date: Location: Time: 2. YOUR VEHICLE Make: Model: Colour: Registration: Are you the owner of the vehicle? If No, please state the name and address of the registered keeper: Details of damage to vehicle (please attach any photographs, quotes for repairs, etc):

3 Rev 02/15 Page 2 3. OTHER VEHICLE ** ** Without the full registration number, police may not be able to take further action. Make: Colour: Driver details: Model: Registration: Details of damage to vehicle (please attach any photographs, quotes for repairs, etc): 4. DAMAGE TO PROPERTY Details of damage to property (please attach any photographs, quotes for repairs, etc): Owner details:

4 Rev 02/15 Page 3 5. HOW DID THE COLLISION OCCUR? Vehicle manoeuvres: Traffic conditions: Weather: Visibility: At the time of the incident I was: stationary waiting to go ahead stopping turning left turning right carrying out a turn in the road overtaking going ahead entering a lay-by leaving a lay-by entering a side road leaving a side road Traffic conditions were: heavy medium light very light The weather was: fine cloudy dull rainy snowing The visibility was: bright sunlight clear mist spray fog dark street light on Was there any conversation with the other driver? If so what was said:

5 Rev 02/15 Page 4 6. PLEASE DRAW A SKETCH PLAN OF THE ROAD TRAFFIC INCIDENT

6 Rev 02/15 Page 5 7. WITNESS DETAILS Name Address Tel no(s) Name Address Tel no(s) Name Address Tel no(s) 8. YOUR DRIVING AND VEHICLE DOCUMENTS This part of the form to be completed in ALL cases Driving licence no: Type: Full Provisional Insurance details: Company: Start date: Certificate no: Expiry date: Signature: Date: Not disclosable Signature:..

7 Rev 02/15 Page 6 9. REPORTING PERSONS DETAILS Full name: Home address: Postcode: Date of birth: address: Home tel no: Gender: Place of birth: Mobile: Work tel no: Preferred means of contact (specify details for vulnerable/intimidated victims and witnesses only): Dates when you are unavailable to attend court if required: I consent to police having access to my medical record(s) in relation to this matter (obtained in accordance with local practice). I consent to my medical record in relation to this matter being disclosed to the defence. I consent to the statement, including my address, being disclosed for the purposes of civil proceedings, e.g. to solicitors, insurance companies acting for either party in the event of a personal injury claim.