0800 825 0081 motor@redsealclaims.com

Commercial Vehicle Accident Report Form

You will need:

– Driving Licence Code. This can be found at https://www.gov.uk/view-driving-licence and requires you to input your driver number and national insurance number in order to generate the unique code.
– Copy of V5

[[[["field186","equal_to","No"]],[["show_fields","field8"]],"and"],[[["field188","equal_to","No"]],[["show_fields","field27,field28,field29,field30,field31,field32,field33,field34,field36,field37,field38,field190"]],"and"],[[["field191","equal_to","Yes"]],[["show_fields","field178"]],"and"],[[["field44","equal_to","Yes"]],[["show_fields","field45"]],"and"],[[["field47","equal_to","Yes"]],[["show_fields","field48"]],"and"],[[["field55","equal_to","Yes"]],[["show_fields","field56"]],"and"],[[["field74","equal_to","Yes"]],[["show_fields","field75"]],"and"],[[["field76","equal_to","Yes"]],[["show_fields","field77"]],"and"],[[["field78","equal_to","Yes"]],[["show_fields","field79"]],"and"],[[["field80","equal_to","Yes"]],[["show_fields","field81"]],"and"],[[["field84","equal_to","No"]],[["show_fields","field85,field87,field88,field89,field90"]],"and"],[[["field193","equal_to","Yes"]],[["show_fields","field95,field96,field97,field98,field99"]],"and"],[[["field194","equal_to","Yes"]],[["show_fields","field100,field101,field102,field103"]],"and"],[[["field143","equal_to","Yes"]],[["show_fields","field144"]],"and"],[[["field144","equal_to","Yes"]],[["show_fields","field147,field146"]],"and"],[[["field145","equal_to","Yes"]],[["show_fields","field196"]],"and"],[[["field151","equal_to","Yes"]],[["show_fields","field152,field153,field154"]],"and"],[[["field154","equal_to","Yes"]],[["show_fields","field156"]],"and"],[[["field191","equal_to","No"]],[["hide_fields","field178"]],"and"],[[["field216","equal_to","Yes"]],[["show_fields","field217"]],"and"],[[["field218","equal_to","Yes"]],[["show_fields","field182"]],"and"],[[["field219","equal_to","Yes"]],[["show_fields","field220,field221,field222"]],"and"],[[["field188","equal_to","Yes"]],[["set_value",null,"-",null,"field27"],["set_value",null,"-",null,"field28"],["set_value",null,"-",null,"field29"],["set_value",null,"-",null,"field30"],["set_value",null,"-",null,"field31"],["set_value",null,"-",null,"field32"],["set_value",null,"-",null,"field33"],["set_value",null,"-",null,"field34"],["set_value",null,"1",null,"field190"],["set_value",null,"-",null,"field36"],["set_value",null,"-",null,"field37"],["set_value",null,"-",null,"field38"]],"and"],[[["field188","equal_to","No"]],[["set_value",null,null,null,"field27"],["set_value",null,null,null,"field28"],["set_value",null,null,null,"field29"],["set_value",null,null,null,"field30"],["set_value",null,null,null,"field31"],["set_value",null,null,null,"field32"],["set_value",null,null,null,"field33"],["set_value",null,null,null,"field34"],["set_value",null,null,null,"field190"],["set_value",null,null,null,"field36"],["set_value",null,null,null,"field37"],["set_value",null,null,null,"field38"]],"and"]]
1 Step 1
Section One - Policyholder
Policy No.
Claim Reference
Name
Date of Birth
Trading Title
Private Address
0 /
Business Address
0 /
Full Time Occupation
Any Part Time Occupation
Private Tel
Business Tel
Mobile Tel
BrokerIn non-commercial form but not commercial?
Section Two - Driver (or last permitted driver) details
Namefull name
Dateof Birth
Address
0 /
F-T Occupation
P-T Occupation
Private Tel
Business Tel
Mobile Tel
Licence No.
Date Test Passed
Relationship to Policyholder
Dateprivate hire driving licence obtained
Dateprivate hire driving licence expires
Issuing body of private hire driving licence (council/TFL)
Please give details of previous accidents/claims/losses. If none, state none.
Date of IncidentCircumstancesCost
×
×
(2)
Please give details of all previous convictions including non-motoring convictions (which are not spent) any convictions pending and any County Court Judgments. If none, state none.
Date of ConvictionConviction Type and CircumstancesFine / Sentence
×
×
(2)
Paste copy of your unique DVLA code.Please supply photo ID and the unique code to view and secure a copy of your license history from the DVLA. This can be found at https://www.gov.uk/view-driving-licence  and requires you to input your driver number and national insurance number in order to generate the unique code. Please paste the unique code which has a one time access within a 21 day time period below.
Photo ID of your private hire driving licence
Upload
Give details of any physical defects or infirmities
Has Insurance ever been cancelled or refused?If yes, provide details
If yes, give insurers details
0 /
Section Three - usage of vehicle
State the exact use of the vehicle at the time of the incidentThe words BUSINESS / PLEASURE are not sufficient.

State exact details of journey.

Travelling from
Travelling to
If yes, give particulars and details of Goods in Transit and Goods in Transit insurers
0 /
How many passengers were being carried?
Provide details of passengers
NameAddressContact Number
×
×
(2)
Section Four - Particulars of vehicle / ownership
Vehicle Make / Model
Registration Number
Date of Registration
Engine Size
GVW
Colour
Mileage
Import?
Date of Purchase
Price Paid
Method of Payment
Current Value
Name and Address of person/company from whom vehicle was purchased?
0 /
If your vehicle is registered for Public or Private Hire please list the reference and issuing body of licence?
0 /
Photo ID of your vehicle licence
Upload
MOT Reference Number
Expiry Date
Expiry Date
If yes, give full details
0 /
If yes, give full details
0 /
Give details of any recent repair / maintenance work on the vehicle
0 /
Does the vehicle have any distinguishing features?
0 /

If no, please state the details of the registered owner of the vehicle.

Name
Relationship to Policyholder
Address
0 /
Telephone No.
Give details of any HP or finance company interest in the vehicle
0 /

If yes, please clarify the following.

Who paid for the vehicle?Insured / Named Driver / Other
What is their relationship to the vendor?(if any)
If log book is not in the vendors name state reason, if known
Section Five - The accident scene
Accident Date
Accident Time
Locationyou can type the rough address and specify further by dragging the pin on the map
Weather and road conditions
What was the speed limit in force?
What road signs and markings were there?
What was the width of the road?
Speed of insured vehicle prior to incident
Speed of third party vehicle prior to incident
Distance of insured vehicle from near side kerb
Distance of third party vehicle from near side kerb
What lights were displayed by the insured vehicle?
What lights were displayed by the third party vehicle?
What signals were given by the insured vehicle?
What signals were given by the third party vehicle?
What warnings were given by the insured vehicle?
What warnings were given by the third party vehicle?
Section Six - Accident description and diagram
Who was to blame for the incident in your opinion?
0 /
Please provide a detailed explanation of exactly how the incident occurred
0 /
Please upload a sketch of the road(s) showing the position of the vehicles at the point of impact. Indicate direction and track by arrows. Please show road signs and markings, pedestrian crossings and direction of nearest towns.
Upload
Please upload a copy of dash cam footage
Upload
Section Seven - Damage to your vehicle
If comprehensive cover please upload two competitive estimates
Upload
Describe damage to vehicle
0 /
Upload any images showing damage to the vehicle
Upload
If you have not received a quote what is the estimated cost of repair
Where can the vehicle be inspected?
0 /
When can the vehicle be inspected?
Name of repairer
Address of repairer
0 /
Telephone
Section Eight - Third Party Details
Damage to other vehicles and property not owned by you or in your custody or control
Make of vehicle and Registration NumberDamage Details (state if vehicle was mobile after incident)Was vehicle mobile after incident?Name / Address /Tel Number of owner and / or driverName and Address of InsurerPolicy NumberHow many passengers were in this vehicle
×
×
(2)
Details of Injuriesincluding to your passengers
Name / Address and Telephone Number of Injured personApprox AgeNature of Injuries Specify if own passenger / TP passenger / pedestrianWas seat belt worn?
×
×
(2)
Give name and address of Hospital
0 /
Please provide details
0 /
Please upload any third party correspondence, notice of prosecution or other proceedings.
Upload
Section Nine - Police Details
If yes, please provide the name and address of station.
0 /
Police Incident reference
If yes, give details
0 /
Section Ten - Witness Details
Please provide details of all passengers and independent witnesses.
Name / Address of own passengersName / Address of any other witnesses
×
×
(2)
Section Eleven - Additional Information
Please provide any additional information which may be helpful to us in dealing with your claim.
0 /
Section Twelve - Declaration
Please read carefully before signing
I hereby confirm that the above information is a true and accurate statement. Unless Red Seal Resources hear from you to the contrary within the next 24 hours the above contained information will be deemed to be a true and accurate record of events.
I declare that the above statements are true and correct to the best of my knowledge and belief. I hold no other policy in addition to this one indemnifying me in respect of this claim. I have not withheld from the Insurers any information with my knowledge connected with the loss and I agree to provide the Insurers with any further information or documentation as may be required. I hereby confirm that Red Seal Resources Ltd have my authority to recover any outlays on my behalf for monies paid under this contract of insurance in relation to this event. If my vehicle is a total loss I agree that the company may have my permission to remove the vehicle to safe and free storage pending settlement of this claim. I understand that any attempt to make a fraudulent claim may result in prosecution.
Signatureof driver or last person in charge of vehicle
Signatureof Policyholder
Dateagreed
Dateagreed
Agreement
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