Vehicle Hire GB Ltd :: report an accident

Report An Accident

Booking Ref *

Driver or Person in Charge of Vehicle

Title *

First name *

Last name *

Country *

Address *

Postcode *

County *

Town *

Occupation *

DOB *

Licence Number *

Driving licence held *

Date test passed *

Length of recent and regular driving experience in the UK etc. *

Have you been convicted of any motoring offences *

Yes

Motoring offence details

Have you any physical infirmity, or defective vision or hearing, or lost a limb or an eye *

Yes

Physical infirmity details

Names and Addresses of Witnesses

Independent

Passengers (State if injuries sustained by any such person, and, if so the nature thereof)

Injured Persons

Give name(s) and address(es) of any injured persons (other than occupants of your car)

Nature of Injuries

Particulars of Vehicle

Reg. No. *

Year of Make *

CC's *

Colour *

Make & Model *

VIN/Chassis Number *

Travelling from *

Travelling to *

What was the purpose of the journey (The word PRIVATE is not sufficient) *

How many passengers were being conveyed *

State nature and weight of any goods carried, and gross vehicle weight (Commercial Vehicles only)

Particulars of Accident

Date and time of the accident *

Where did the accident occur *

Class of road *

Approximate width of road *

Condition of the road *

Your position on the road *

If driving on n/s how far out were the n/s wheels from the kerb

At what speed were you travelling prior to the accident *

Was your horn sounded *

Yes

If dark, what lamps were showing on your vehicle

Who in your opinion was to blame

Give name if other than yourself or driver

Police Evidence

Did the Police take evidence or particulars *

Yes

If so, give his/her Number and Station

Was he/she a witness

Yes

Did he/she indicate that anyone may be prosecuted

Yes

If so, whom

Particulars of Third Party Vehicle Involved or Other Property Damaged

Name and address of the owner

Name and address of the driver

Make, model, reg. no. and colour

Nature of damage

Has notice of any claim been given to you

Yes

Details of the third party insurers if known

If in writing, forward unanswered. If verbally, give particulars

Accident Details

Explain fully how the accident occurred *

Damage Particulars

Give Full Particulars of the Damage to the Vehicle *

Is the car still mobile *

Yes

If not, please state the address where the motor vehicle may be examined

Is the vehicle still in use *

Yes

Additional Information

Please give any further information which may be of use in deciding liability

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Vehicle Hire GB Ltd

Report An Accident

Driver or Person in Charge of Vehicle

Names and Addresses of Witnesses

Injured Persons

Particulars of Vehicle

Particulars of Accident

Police Evidence

Particulars of Third Party Vehicle Involved or Other Property Damaged

Accident Details

Damage Particulars

Additional Information

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