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Motor Vehicle Insurance Report Form
Motor Vehicle Accident Insurance Report Form
Please complete fully and return to the Insurance Office in A305, or email to [email protected] within five days of the accident. Your School or Service will be responsible for the excess of 250 so you should let your Finance Officer know about the incident. The excess will need to be paid for both University owned vehicles and hire vehicles.
Malicious damage should be reported to the police on discovery.
All questions should be answered as fully as possible and the form should be signed by the driver.
Details of the vehicle involved
Registration Number: Click here to enter text.
Vehicle ownership: University owned/leased Hire Vehicle
Type of Vehicle:Minibus Car other (please specify) Click here to enter text.
Make & model: Click here to enter text.
Engine size: Click here to enter text.
Driver
Name: Click here to enter text.Date of birth: Click here to enter text.
Home address: Click here to enter text.
Contact Telephone number: Click here to enter text.
School or Service: Click here to enter text.Job title: Click here to enter text.
Length of time license held: Click here to enter text.
Any motoring convictions (please specify): Click here to enter text.
Incident details
Purpose of journey: Click here to enter text.
Date of incident: Click here to enter text.
Time of incident:Click here to enter text.
Location: Click here to enter text.
Speed at impact: Click here to enter text.
Road/weather conditions: Click here to enter text.
Day light/streetlight: Click here to enter text.
Any injuries? YES (please give details): Click here to enter text. NO
Number of occupants in your vehicle: Click here to enter text.
Incident description: Click here to enter text.
Who do you think was at fault and why? Click here to enter text.
Description of damage to our vehicle: Click here to enter text.
Please attach to this form photographs of the damaged vehicle and accident location (if available)
Witnesses
Name: Click here to enter text.
Address: Click here to enter text.
Telephone number: Click here to enter text.
Please draw a sketch of the incident
Third party details (if applicable)
Name of third party: Click here to enter text.
Address: Click here to enter text.
Contact number: Click here to enter text.
Third party vehicle registration: Click here to enter text.
Make & Model: Click here to enter text.
Description of damage to the third party vehicle (please attach photographs if available): Click here to enter text.
Number of passengers in Third Party vehicle: Click here to enter text.
Any concerns re Third Party Vehicle ie sudden/sharp breaking, no visible brake lights?
YES (please give details) Click here to enter text.
NO
Property damage/injured persons (if applicable)
Property damage
Owners name: Click here to enter text.
Address: Click here to enter text.
Description of property: Click here to enter text.
Extent of damage: Click here to enter text.
Injured persons
Please state name and address (whether driver, pedestrian, etc.); full details of injury; medical attention required; name of hospital (if applicable):
Click here to enter text.
Other information
Were the Emergency Services informed? Click here to enter text.
Did they attend? Click here to enter text.
Witness details: Click here to enter text.
Police crime/reference number: Click here to enter text.
Declaration
I declare that the above answers are true and correct.
Name: Click here to enter text.Position: Click here to enter text.
Signature: Click here to enter text.
Please email the completed form to the Insurance Office or alternatively you can print a copy and return it to us in A305.
Administrative Assistant/E&F, Insurance/ July2015/v1/July2016
Uncontrolled if printed