Vehicle Accident Report Form

Vehicle Accident Report Form
Submission date*

DayMonthYear
Date
Group Company*
Employee name*
Vehicle Registration*
Accident Details
Incident date and time*

DayMonthYear
DateHourMinutes
Incident location*
Weather conditions*
Road surface conditions*
ABCA vehicle speed (mph) BEFORE impact*
ABCA vehicle speed (mph) AFTER impact*
What lights were showing on ABCA vehicle?*
Circumstances of the accident i.e. what happened*
Damage to ABCA vehicle*
Photo 1 of damage to ABCA vehicle*

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Photo 2 of damage to ABCA vehicle

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Photo 3 of damage to ABCA vehicle

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Photo 4 of damage to ABCA vehicle

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Photo of accident location*

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Plan of accident showing road markings, signs & direction of travel

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Upload a photo of a detailed sketch Cancelof
Did you sound your horn before impact?*
Who was at fault?*

MyselfOther partyBoth me and the other partyNo One

Details of other vehicles involved
Number of other (non-ABCA) vehicles involved in the accident, in addition to your vehicle*
Name of other driver*
Address of other driver

Street Address

Street Address Line 2

CityState / Province

Post Code
Contact number of other driver*
Owner of the other vehicle (if different to the driver)*
Registration of other vehicle*
Make and model of the other vehicle*
Colour of the other vehicle*
Insurer of other driver*
Policy Number of other driver*
What lights were showing on the other vehicle?*
Damage to the other vehicle*
Photo 1 of damage to other vehicle*

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Photo 2 of damage to other vehicle

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Photo 3 of damage to other vehicle

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Photo 4 of damage to other vehicle

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Photo 5 of damage to other vehicle

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Did the other driver sound their horn before impact?*
Name of the 2nd other driver*
Address of 2nd other driver*

Street Address

Street Address Line 2

CityState / Province

Post Code
Contact number of 2nd other driver*
Owner of the 2nd other vehicle (if different to the driver)*
Registration of the 2nd other vehicle*
Make and model of the 2nd other vehicle*
Colour of the 2nd other vehicle*
Insurer of 2nd other driver*
Policy Number of the 2nd other driver*
What lights were showing on the 2nd other vehicle?*
Damage to the 2nd other vehicle*
Photo 1 of damage to 2nd other vehicle*

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Photo 2 of damage to 2nd other vehicle

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Photo 3 of damage to 2nd other vehicle

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Photo 4 of damage to 2nd other vehicle

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Photo 5 of damage to 2nd other vehicle

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Did the 2nd other driver sound their horn before impact?*
Name of 3rd other driver*
Address of 3rd other driver*

Street Address

Street Address Line 2

CityState / Province

Post Code
Contact number of 3rd other driver*
Owner of the 3rd other vehicle (if different to the driver)*
Registration of the 3rd other vehicle*
Make and model of the 3rd other vehicle*
Colour of the 3rd other vehicle*
Insurer of 3rd other driver*
Policy Number of the 3rd other driver*
What lights were showing on the 3rd other vehicle?*
Damage to the 3rd other vehicle*
Photo 1 of damage to 3rd other vehicle*

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Photo 2 of damage to 3rd other vehicle

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Photo 3 of damage to 3rd other vehicle

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Photo 4 of damage to 3rd other vehicle

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Photo 5 of damage to 3rd other vehicle

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Did the 3rd other driver sound their horn before impact?*

Other Information
Were any injuries sustained by you or anyone else?*
With every vehicle incident reported it is a requirement to complete the H&S Incident report. If there is no injuries to report then the form will need completing as a near miss. Please click here to access that form.
Has the above H&S Incident report been completed?*
Were there any witnesses to the Accident, apart from the other other drivers who were involved?*
How many witnesses were there?*
Name of Witness*
Address of witness*

Street Address

Street Address Line 2

CityState / Province

Post Code
Contact number of witness*
Name of 2nd Witness*
Address of 2nd witness*

Street Address

Street Address Line 2

CityState / Province

Post Code
Contact number of 2nd witness*
Name of 3rd Witness*
Address of 3rd witness*

Street Address

Street Address Line 2

CityState / Province

Post Code
Contact number of 3rd witness*
Did the Police attend or were they contacted?*
Name of Police Officer*
Officer badge number*
Contact number of Officer*
Incident reference number

Declaration
Your DOB*

DayMonthYear
Date
Date you passed your test*

DayMonthYear
Date
Type of Licence Held by you*
Have you been involved in any other accidents or suffered any other losses within the last 5 years (regardless of blame)? *
Please provide details of other accidents or losses within the last 5 years.*
Do you have any motoring convictions within the last 5 years*
Date of Conviction*

DayMonthYear
Date
Conviction Code*
Points Issued*
Conviction Details*
Do you have any pending motoring convictions*
Date of alleged driving offence*

DayMonthYear
Date
Code of alleged driving offence*
Details of alleged driving offence*
Have you ever been advised not to drive by DVLA or have any medical conditions that affect your licence*
Reason(s) why you have been advised not to drive by the DVLA*
Signature to confirm that the information submitted on this form is accurate
Should be Empty:

Vehicle Accident Report Form

Accident Details

Details of other vehicles involved

Other Information

Declaration