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
Address in full including postcode
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 Address in full including postcode
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
yes
no
yes
no
yes
no
Has the driver any motoring convictions, offences including fixed penalties or any pending prosecutions during the past 5 years?
Date of Date of Disqualifying
Conviction Offence code offence Fine period If 'yes' please give details
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?
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? Please note Select Repairer applies to Private Car policies only
If 'no' can it be moved to Private cars only a Select Repairer?
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 Address
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/
female Age Registration or details of vehicle
approx if not known
Injury
Second person Name Male/
female Age Registration or details of vehicle
Approx if not known
Injury
continued
yes
no
yes
no
Third person Name Male/ female Age Registration or details of vehicle
approx if not known
Injury
First person Second person Third Person
Were they wearing seat belts or helmets as appropriate? Where more than three people injured?
If no one was injured please tick box
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
Address
Postcode Second witness -name
Address
Postcode Third witness -name
Address
Postcode Describe fully what happened continue on separate sheet/overleaf if necessary
Continued
yes
no
yes
no
yes
no
yes
no
yes
no
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.
