STATEMENT OF TRUTH

Our Reference: PA/PAAH1/362921

*Please CHECK and COMPLETE in CAPITALS and BLACK INK*
1) Claimant details
Your Full Name:

Kayne Gascoine

Your Full Address:

10 Banksman Close Nottingham NG3 3EW

Occupation:
D.O.B:

Student
27/07/1996

2) Details of the driver you believe is to blame for the accident.

Name:
Address:

Telephone:
Description of Driver: Old but active, grey hair, quiet tall around 6 foot
How did you obtain these details? visually seen him after the crash

3) Vehicle being driven by the person you believe is to blame for the accident.
Registration Number:
FM62 EOR
Make/Model:
PEUGEOT 508 ALLURE SW HDI (2.0) ESTATE DIESEL
Colour:
BLACK
Passengers in Vehicle: 1
Please indicate number of

4) Accident circumstances
Date of Incident:

17/06/2015

Time of Incident:

12:30

Exact Location of
Incident:

21 Manvers Street NG2 4PB Nottingham Nottinghamshire

5) Independent witnesses

(not known to you prior to the accident)

YES
Names Addresses of any witnesses: Ron Malone, Flat above 12 Baker Street, Hucknall, NG15 7AS
Please note they must be independent and must have seen the incident occur

6) Police Involvement
YES
Police Details: PC3094Collins - Incident No: 000539-17062015
Please include Officer Name/No, Incident No

Our Reference: PA/PAAH1/362921

7) Description of Incident
I was travelling home from sixth form, i went the same route i do most days.
I was travelling down the road in the middle of my lane at roughly 15-20mph as there is roadworks on that road,
the speed limit is 30mph on that road. as i was travelling down the road it becomes 2 lanes after a crossroad,
where turning vehicles join the left hand side lane, there is 2 lanes, i was in the right lane he was in the left lane,
there is cones that seperate the 2 lanes for part of the road, as soon as the other driver reached the end of the cones,
he changed into my lane, blocking my path and leaving me nowhere to go, i broke as much as i could and sounded
my horn hopeing he would move from my lane before i hit him. he continued changing lane and i ended up hitting
the back right hand side of the car and fell off my bike into the opposite lane of the road

8) Sketch of Incident

Kayne Gascoine

description are a true and accurate statement of events.

Kayne Mark Gascoine

26/06/2015