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 Get Licence Code 1 Step 1 Section One - Policyholder Policy No. Claim Reference Name Date of Birth VAT RegisteredYesNo Email Trading Title Private Address0 / Is your business address the same as your private address?Select An OptionYesNo Business Address0 / Full Time Occupation Any Part Time Occupation Private Tel Business Tel Mobile Tel BrokerIn non-commercial form but not commercial? CoverIn non-commercial form but not commercial?Select An OptionCompTPF&TTPO Section Two - Driver (or last permitted driver) details Is the driver (or last permitted driver) the Policyholder?Select An OptionYesNo Namefull name Dateof Birth Address0 / F-T Occupation P-T Occupation Private Tel Business Tel Mobile Tel Type of LicenseSelect An OptionFull UK OnlyFull UK with Private HireUK Provisional OnlyEU Licence OnlyEU Licence with private HireUnlicenced Licence No. Date Test Passed Relationship to Policyholder Agency Driver?Select An OptionYesNo Is the driver using the vehicle for taxi/private hire purposes?Select An OptionYesNo Dateprivate hire driving licence obtained Dateprivate hire driving licence expires Issuing body of private hire driving licence (council/TFL) Any convictions?Select An OptionYesNo Please give details of previous accidents/claims/losses. If none, state none.Date of IncidentCircumstancesCost××+ Add Row(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××+ Add Row(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 licenceUpload Give details of any physical defects or infirmities Has Insurance ever been cancelled or refused?If yes, provide details Was vehicle being used with your consent?Select An OptionYesNo Was driver breathalysed?Select An OptionYesNo If yes, positive or negative?Select An OptionPositiveNegative Does driver have any motor insurance policies in their own name?Select An OptionYesNo If yes, give insurers details0 / 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 Were any goods being carried?Select An OptionYesNo If yes, give particulars and details of Goods in Transit and Goods in Transit insurers0 / How many passengers were being carried? Provide details of passengersNameAddressContact Number××+ Add Row(2) Was vehicle being used with Policyholders consent?Select An OptionYesNo 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 Is vehicle left hand drive?Select An OptionYesNo Method of Payment Current Value Is the vehicle fitted with a dash cam?Select An OptionYesNo 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 licenceUpload Does the vehicle have a current MOT?Select An OptionYesNo MOT Reference Number Expiry Date Does the vehicle have a current Road Fund Licence?Select An OptionYesNo Expiry Date Has the vehicle been modified?Select An OptionYesNo If yes, give full details0 / Was there any pre-incident damage?Select An OptionYesNo If yes, give full details0 / Give details of any recent repair / maintenance work on the vehicle0 / Does the vehicle have any distinguishing features?0 / Is the registered owner of this vehicle the same as the policy holder?Select An OptionYesNo If no, please state the details of the registered owner of the vehicle. Name Relationship to Policyholder Address0 / Telephone No. Give details of any HP or finance company interest in the vehicle0 / Is the vehicle owned by the Policyholder but not yet registered?i.e. stock vehicleSelect An OptionYesNo 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 Time00010203040506070809101112000102030405060708091011121314151617181920212223242526272829303132333435363738394041424344454647484950515253545556575859 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 occurred0 / 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 footageUpload Section Seven - Damage to your vehicle If comprehensive cover please upload two competitive estimatesUpload Describe damage to vehicle0 / Upload any images showing damage to the vehicleUpload If you have not received a quote what is the estimated cost of repair Is the vehicle still in use?Select An OptionYesNo Where can the vehicle be inspected?0 / When can the vehicle be inspected? Name of repairer Address of repairer0 / Telephone Section Eight - Third Party Details Damage to other vehicles and property not owned by you or in your custody or controlMake 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××+ Add Row(2) Was anybody injured as a result of the incident?Select An OptionYesNo Details of Injuriesincluding to your passengersName / Address and Telephone Number of Injured personApprox AgeNature of Injuries Specify if own passenger / TP passenger / pedestrianWas seat belt worn?××+ Add Row(2) Did an Ambulance attend the scene?Select An OptionYesNo Was anybody taken to Hospital?Select An OptionYesNo Were they detained?Select An OptionYesNo Give name and address of Hospital0 / Has any claim been intimated against you, either verbally or in writing?Select An OptionYesNo Please provide details0 / Please upload any third party correspondence, notice of prosecution or other proceedings.Upload Section Nine - Police Details Was the incident reported to the Police?Select An OptionYesNo If yes, please provide the name and address of station.0 / Police Incident reference Is any prosecution of the driver likely?Select An OptionYesNo If yes, give details0 / Section Ten - Witness Details Please provide details of all passengers and independent witnesses.Name / Address of own passengersName / Address of any other witnesses××+ Add Row(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 AgreementBy checking this box you agree to let us collect the above information entered by you in this form. We will use this data to handle your claim and contact you regarding it.By checking this box you have read and agree to our Privacy Policy Submit Form If you are having trouble submitting the form then please reload your page and try again. Previous Next FormCraft - WordPress form builder
