Motor Vehicle Accident Report Form
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1 Motor Vehicle Accident Report Form Your Car, Your Choice Know Your Rights Service & Quality Guaranteed One Call Does It All
2 Owner s Particulars (PLEASE COMPLETE IN BLOCK LETTERS) Full Name / Company Occupation or Business Ph. Home Work Mobile Fax ABN/ACN Driver s Particulars (PLEASE COMPLETE IN BLOCK LETTERS) If same write in AS ABOVE Mr / Mrs / Ms Surname Other Names Ph. Home Ph. Work Mobile D.O.B / / Occupation Year Licenced Licence No. Expiry Date State of Issue Licence Type Relationship to Owner Was Vehicle Used with Owners Consent? Y N Your Vehicle Year of Manufacture Make Model Body Type Colour Registration No. Manual/Automatic Your Insurance Details Name of Your Insurance Company Policy No. Policy Type (4) Comprehensive 3rd Party Is this Vehicle Financed? Y N If Yes, Contract No. Name of Finance Company Agreement Type
3 Accident Details Date / / Time Location Weather Conditions (4) Wet Dry Foggy Sunny Overcast Other Speed Allowed Km/ph Speed of Your Vehicle? Km/ph Speed of Other Vehicle? Km/ph What Warning Was Given by You (Horn or Other) Road Conditions (Sealed, Gravel, Dirt or Other) Who do You Consider is at Fault? Give Reason Did anyone Admit Fault? If Yes, Who? Accident Description (PLEASE COMPLETE IN BLOCK LETTERS) To be Completed by Driver add another page if required State Conversation With Other Drivers Witnesses or Others Was Your Vehicle Driveable? Y N If No, Name of Towing Company Location of Vehicle
4 Vehicle Damage (Mark All Damaged Areas With X) Your Vehicle Other Vehicle Plan (Please Sketch Scene of Accident and Show All Traffic Lights, Stop & Giveway Signs) Indicate as Follows Street/ Intersection Indicate direction of North by Arrow Curved Street Pedestrian Your Vehicle Other Vehicle (Direction of Traffic Shown by Arrow) Indicate Traffic Control Signs e.g. STOP (Sign) STOP Particulars of all Passengers in Your Vehicle (PLEASE COMPLETE IN BLOCK LETTERS) Name Age Sex M / F Ph Name Age Sex M / F Ph Name Age Sex M / F Ph Name Age Sex M / F Ph
5 Police Did the Police Attend? Y N If No, Was The Accident Reported to The Police? Y N If Yes, which Police Station? Date Reported / / Name Of Attending Police Officer Police No. Did Police Charge Anyone? If Yes, Who? Nature of Charge Did you consume any Alcohol or take any Drugs 12 hours prior to the Accident? Y N Did you undergo a Breath or Blood Test Analysis? Y N If Yes, What was the Result? Replacement Vehicle Do you use Your Motor Vehicle for Business Purposes? Y N Do You Require a Hire Car? Y N Can You Provide Evidence in Support of the Need for a Substitute Motor Vehicle? (e.g. Tax records, letters from Employer or Accountant) Y N Driver of Other Vehicle (PLEASE COMPLETE IN BLOCK LETTERS) Vehicle 1 Name D.O.B. / / Mobile Licence No. Name of Registered Owner Registration No. Make of Vehicle Model Name of Insurance Company Policy No. Claim No.
6 Details of Other Drivers and Vehicles Involved (PLEASE COMPLETE IN BLOCK LETTERS) Vehicle 2 - If applicable Name Registration No. Mobile Vehicle 3 - If applicable Name Registration No. Mobile Particulars of Independent Witness (PLEASE COMPLETE IN BLOCK LETTERS) Witness 1 - If applicable Name Viewed Accident From Witness 2 - If applicable Name Viewed Accident From Declaration I declare the aforementioned to be true and correct. Signature of Driver Signature of Owner Date / / Date / /
7 AUTHORITY TO ACT I, (name & surname) of (address) Being the owner / driver of (make & model) Registration Number Reference Hereby authorise and agree to the following conditions for Accident Solutions to represent my interest: a. Tow or drive my damaged vehicle as necessary for storage, assessment of damage, and/or repairs. b. Prepare and submit estimate for repairs. c. Retain my vehicle until repairs have been completed and paid for. e. Commence legal proceedings in my name to recover the cost of repairs and/or loss and damage to my vehicle, and any other losses including hire car costs and/or loss of income, for this purpose I authorise lawyers to be instructed to take whatever action is reasonably necessary to recover my loss and damage. f. I appoint you my attorney to do any act, to sign any documents, and to do anything else on my behalf that is necessary or incidental to repairing, or claiming for the loss or damage to, my vehicle, I specifically authorise you to deal on my behalf with any insurers, repairers, assessors, law enforcement agencies, storage and/or towing businesses and any other persons who are in any way involved with the damage, storage or repair of my vehicle. g. I agree to indemnify you for any costs that you will incur on my behalf, or for which you remain liable in relation to the repairs to my vehicle including any legal costs in the event that I am found liable by a court, either in whole or in part for the accident occurring. h. I am aware that you may receive a commission or commissions in relation to arranging for the repair, storage, or other work done in relation to my vehicle. i. I agree that you will be under no legal liability to me if for any reason you are not able to have the repairs carried out on my vehicle. I agree that I will provide you with all further information you require from me on request in relation to my vehicle, any insurance, and anything relevant to making an insurance claim. j. I agree to sign any documents, and co-operate with lawyers appointed by you to represent me in relation to this case, and to attend court and give evidence if required to do so. k. EVERYTHING I HAVE TOLD YOU IN CONNECTION WITH MY VEHICLE, THE ACCIDENT IN WHICH IT WAS DAMAGED, AND THE CIRCUMSTANCES OF MY CLAIM ARE TRUE AND CORRECT IN EVERY DETAIL. Owner Witness Date / /
8 Our Guarantee All Repairs carried out by Accident Solutions members are guaranteed in writing. Please ask you repairer for a written Guarantee Certificate on completion of repairs to your vehicle. Accident Solutions First Floor, 7 Cochrane St, Mitcham VIC P.O. Box 4466 Ringwood VIC Fax:
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