Accident Report Form Policyholder (Rental Company) Policy No : Policy Holders Address : Telephone No : Hirer’s Name : Hirer’s Address : Policy Holder : Fax No : E-mail : Vehicle Reg. No : Year of Manufacture : Colour : Registered Owner : Make/Model : Date of Purchase : Carrying Capacity/G.V.W. : c.c. : Price Paid (£) : No. of doors including tailgate : Current Market Value (£) : Use State reason for journey (private is not sufficient) : Yes No Was the vehicle being used for business? Yes No Was the vehicle being used for business? Yes No If yes, give details of goods/samples carried and weight of load : Yes No No. of Occupants at moment of incident including Driver : Yes No If person other than the Insured was driving, was it with your permission : Yes No Driver or last person in charge of vehicle (even if vehicle was parked and left unattended THIS SECTION MUST BE ANSWERED Name : Address : Occupation(s) : Is Licence : Is Driver main user? : Full : Provisional : Date Test Passed : Has Driver (a) Ever been convicted or is prosecution pending? : Yes No (b) Been involved in any accident or made any claim in the last 3 years : Yes No (c) Ever been refused insurance, had a policy cancelled, renewal declined or special terms imposed? : Yes No (d) Any mental or physical infirmity? : Yes No If yes answered to any of the above questions, give details below Third Party Vehicle(s) Name and address of driver : Post Code : Tel. No. : Name and address of driver : Post Code : Tel. No. : Name and address of driver : Post Code : Tel. No. : Name and address of driver : Post Code : Tel. No. : Third Party Propert Name and address of owner : Post Code : Details of damage : Injuries Name and address : Third Party or Passenger : Were seat belts being worn? : Age(s) : Nature of injury : Was hospital treatment given? : Name and address : Third Party or Passenger : Were seat belts being worn? : Age(s) : Nature of injury : Was hospital treatment given? : Name and address : Third Party or Passenger : Were seat belts being worn? : Age(s) : Is the vehicle leased? (If yes, provide details below*) : Yes No Is there any outstanding HP/Financial Interest? (If yes, provide details below*) : Yes No Is the vehicle still in use? : Yes No Was the vehicle towed to a garage? : Yes No If tyres damaged, state mileage covered : Yes No If the policy covers the damage sustained by your vehicle and same remains in use, please obtain and forward more than one estimate for our consideration. If repairs will not be economic we may wish to move the vehicle to safe and free storage. We should appreciate your permission to do this. If you decline you could become liable for any additional charges which are then incurred. May we move the salvage? Damage to third Party vehicle(s) Indicate direction and area of damage Was the vehicle towed to a garage : Yes No Make/Model : Registration Number : Damage to third Party vehicle(s) : Was the vehicle towed to a garage? : Yes No Make/Model : Registration Number : No of Occupants : Accident details Date : Name of Road(s) : Width of road : Speed of vehicles : Time ( am/pm Exact Location. ) : Street Lighting : Good Poor None Location : Town Village Distance of insured vehicle from nearside : Speed Limit : Speed of vehicles: Insured vehicle : Third Party vehicle : What warning or signal was given by : Insured : Third Party : What was the condition of the : Road : Weather : What lights were displayed by : Insured : Third Party : Was the accident reported to the police? : Yes No Were statements taken? : Yes No Circumstances Please describe the accident circumstances and make a sketch showing positions of vehicles and direction of travel. Please show all road signs and markings. (If you need more space please use a separate sheet of paper and attach it to this form.) Who, in your opinion, was to blame? Can Insurers or their duly authorised agents admit liability on the policyholder’s/driver’s behalf? : Yes No Witnesses Names and addresses of: A: All independent witnesses : B: All passengers in insured vehicle : You are reminded that the policy conditions require that every letter, writ, summons and process must be notified or forwarded to insurers immediately on receipt. You must also tell us of any impending prosecution, inquest or fatal injury. Do NOT attempt to deal with any Third Party claim yourself or make any offer or admission of liability. Insurers pass information to various anti-Fraud and Theft Registers. The aim is to help us check information provided, and also to prevent fraudulent claims. Under the conditions of your insurance policy, you must tell us about any incident (such as an accident or theft) whether or not it gives rise to a claim. When you tell us about an incident, we will pass information relating to it to the registers. I/WE HEREBY DECLARE that the above statements are true to the best of my/our knowledge and belief, and that the vehicle is not insured except with LIBERTY SYNDICATE MANAGEMENT LIMITED. I/We understand that you may ask for information from other insurers to check the answers I/we have provided. Signature of insured driver : Date :
